Provider Demographics
NPI:1356324131
Name:PARK, DAVID C (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
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 1:1939 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4508
Mailing Address - Country:US
Mailing Address - Phone:858-272-2211
Mailing Address - Fax:
Practice Address - Street 1:1939 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4508
Practice Address - Country:US
Practice Address - Phone:858-272-2211
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10394T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP10394BMedicare ID - Type Unspecified
CAU54208Medicare UPIN