Provider Demographics
NPI:1508302944
Name:VISTAPARK FAMILY OPTOMETRY PC
Entity Type:Organization
Organization Name:VISTAPARK FAMILY OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YUN
Authorized Official - Middle Name:SANG
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-578-6181
Mailing Address - Street 1:428 W CAPITOL EXPY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-1303
Mailing Address - Country:US
Mailing Address - Phone:408-578-6181
Mailing Address - Fax:408-578-0617
Practice Address - Street 1:428 W CAPITOL EXPY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95136-1303
Practice Address - Country:US
Practice Address - Phone:408-578-6181
Practice Address - Fax:408-578-0617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10154T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU36389Medicare PIN