Provider Demographics
NPI:1497701353
Name:PARK, ROBERT (O D)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 WOODWARD CROSSING BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4947
Mailing Address - Country:US
Mailing Address - Phone:770-831-1010
Mailing Address - Fax:
Practice Address - Street 1:3385 WOODWARD CROSSING BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4947
Practice Address - Country:US
Practice Address - Phone:770-831-1010
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA2145152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFQSMedicare ID - Type Unspecified