Provider Demographics
NPI:1275534919
Name:PARK, ROY J (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 S MERIDIAN STE 101
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7590
Mailing Address - Country:US
Mailing Address - Phone:253-848-3000
Mailing Address - Fax:253-840-6514
Practice Address - Street 1:1703 S MERIDIAN STE 101
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7590
Practice Address - Country:US
Practice Address - Phone:253-848-3000
Practice Address - Fax:253-840-6514
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07382200207W00000X
WAMD00048909207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ059228Medicare ID - Type Unspecified
NJH54623Medicare UPIN