Provider Demographics
NPI:1558358937
Name:PARK, DAVID L (OD, MS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:PARK
Suffix:
Gender:M
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4316
Mailing Address - Country:US
Mailing Address - Phone:707-462-7040
Mailing Address - Fax:707-462-7089
Practice Address - Street 1:102 SCOTT ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4316
Practice Address - Country:US
Practice Address - Phone:707-462-7040
Practice Address - Fax:707-462-7089
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7782T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0077820Medicaid
T70226Medicare UPIN
1558358937Medicare NSC
CASD0077820Medicaid