Provider Demographics
NPI:1710229604
Name:TONY PARK OD PLLC
Entity Type:Organization
Organization Name:TONY PARK OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-366-3506
Mailing Address - Street 1:6135 JUNCTION BLVD
Mailing Address - Street 2:COSTCO OPTOMETRY
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2771
Mailing Address - Country:US
Mailing Address - Phone:718-760-7862
Mailing Address - Fax:718-760-7861
Practice Address - Street 1:6135 JUNCTION BLVD
Practice Address - Street 2:COSTCO OPTOMETRY
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2771
Practice Address - Country:US
Practice Address - Phone:718-760-7862
Practice Address - Fax:718-760-7861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
NYTUV 007776261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty