Provider Demographics
NPI:1699391631
Name:PARK, IRENE MINJEE (OD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:MINJEE
Last Name: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 1:5859 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-4737
Mailing Address - Country:US
Mailing Address - Phone:909-706-7213
Mailing Address - Fax:
Practice Address - Street 1:1131 W 6TH ST STE 150
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1116
Practice Address - Country:US
Practice Address - Phone:909-986-0918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist