Provider Demographics
NPI:1225010960
Name:STUDEBAKER, PARK A (OD)
Entity Type:Individual
Prefix:DR
First Name:PARK
Middle Name:A
Last Name:STUDEBAKER
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 1:6901 YANKEE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3321
Mailing Address - Country:US
Mailing Address - Phone:937-434-2021
Mailing Address - Fax:
Practice Address - Street 1:2525 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45419-1505
Practice Address - Country:US
Practice Address - Phone:937-298-0550
Practice Address - Fax:937-298-5404
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3639/T674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9283311Medicare PIN
OHT47824Medicare UPIN