Provider Demographics
NPI:1841402385
Name:ROMY PARK OD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ROMY PARK OD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-641-2007
Mailing Address - Street 1:PO BOX 401240
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89140-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 S RAINBOW BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-1057
Practice Address - Country:US
Practice Address - Phone:702-641-2007
Practice Address - Fax:702-258-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV522152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV26488OtherMEDICAL EYE SERVICES
NV56000OtherDAVIS
NV35421OtherAVESIS
1841402385OtherEYEMED
NV26034OtherSPECTERA
NV291059OtherNVA
NV26488OtherMEDICAL EYE SERVICES
NV100780Medicare ID - Type UnspecifiedO.D. PIN