Provider Demographics
NPI:1821650383
Name:PARK, KRISTINE RACHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:RACHAEL
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:320 SUPERIOR AVE STE 390
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2793
Mailing Address - Country:US
Mailing Address - Phone:949-631-4780
Mailing Address - Fax:
Practice Address - Street 1:10921 WILSHIRE BLVD STE 900
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4003
Practice Address - Country:US
Practice Address - Phone:310-208-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT34525152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist