Provider Demographics
NPI:1164524476
Name:PARK, ALLISON H (OD)
Entity Type:Individual
Prefix:DR
First Name:ALLISON
Middle Name:H
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3600 N VERDUGO RD STE 104
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1258
Mailing Address - Country:US
Mailing Address - Phone:818-937-9102
Mailing Address - Fax:818-330-9611
Practice Address - Street 1:3600 N VERDUGO RD STE 104
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1258
Practice Address - Country:US
Practice Address - Phone:818-937-9102
Practice Address - Fax:818-330-9611
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12850TPA152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFS410AMedicare PIN