Provider Demographics
NPI:1790458487
Name:PARK, SO RI (DOCTOR OF OPTOMETRY)
Entity Type:Individual
Prefix:
First Name:SO RI
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DOCTOR OF OPTOMETRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 N NEWKIRK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-2714
Mailing Address - Country:US
Mailing Address - Phone:646-460-0894
Mailing Address - Fax:
Practice Address - Street 1:1880 KENNETH RD STE 1
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-6344
Practice Address - Country:US
Practice Address - Phone:717-767-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003836152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist