Provider Demographics
NPI:1164822714
Name:PARK, BRIAN EDWARD WONG (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN EDWARD
Middle Name:WONG
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7116 SHERICE CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3041
Mailing Address - Country:US
Mailing Address - Phone:916-607-2833
Mailing Address - Fax:
Practice Address - Street 1:1695 ARDEN WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4004
Practice Address - Country:US
Practice Address - Phone:916-564-5983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15075152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist