Provider Demographics
NPI:1326618273
Name:PARK, JUNHWAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUNHWAN
Middle Name:
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 1:7349 REGATTA WAY
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-7704
Mailing Address - Country:US
Mailing Address - Phone:785-319-9496
Mailing Address - Fax:
Practice Address - Street 1:891 DAWSONVILLE HWY STE 170
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2638
Practice Address - Country:US
Practice Address - Phone:770-718-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003329152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist