Provider Demographics
NPI:1235254095
Name:PARK, JERRY B (OP)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:B
Last Name:PARK
Suffix:
Gender:M
Credentials:OP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 NORTH FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076
Mailing Address - Country:US
Mailing Address - Phone:501-982-1100
Mailing Address - Fax:501-982-0323
Practice Address - Street 1:291 NORTH FIRST STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076
Practice Address - Country:US
Practice Address - Phone:501-982-1100
Practice Address - Fax:501-982-0323
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROP1100081152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
48029Medicare ID - Type Unspecified
T20155Medicare UPIN