Provider Demographics
NPI:1922333004
Name:PARK, AMY LEANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LEANNE
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LEANNE
Other - Last Name:PEDERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10800 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10800 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3043
Practice Address - Country:US
Practice Address - Phone:951-353-4701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA14428TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program