Provider Demographics
NPI:1407078470
Name:KUCIA-PARK, LORI ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:ANN
Last Name:KUCIA-PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 13TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-2202
Mailing Address - Country:US
Mailing Address - Phone:661-725-3795
Mailing Address - Fax:661-725-3797
Practice Address - Street 1:919 13TH AVENUE
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2202
Practice Address - Country:US
Practice Address - Phone:661-725-3795
Practice Address - Fax:661-725-3797
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 11801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0118010Medicaid
CAMK0733394OtherDEA
CAU88145Medicare UPIN
CASD0118010Medicare ID - Type UnspecifiedMEDICARE