Provider Demographics
NPI:1497856124
Name:PARK, HELEN JISOO (OD)
Entity Type:Individual
Prefix:
First Name:HELEN
Middle Name:JISOO
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JISOO
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1465 STATE ROUTE 31 S
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08801-3129
Mailing Address - Country:US
Mailing Address - Phone:908-730-6774
Mailing Address - Fax:
Practice Address - Street 1:1465 STATE ROUTE 31 S
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:NJ
Practice Address - Zip Code:08801-3129
Practice Address - Country:US
Practice Address - Phone:908-730-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13015 T152W00000X
NJ27OA00616900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist