Provider Demographics
NPI:1245368430
Name:PARK, THERESA A (OD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 GATEWAY STREET
Mailing Address - Street 2:SEARS OPTICAL
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1027
Mailing Address - Country:US
Mailing Address - Phone:541-741-7049
Mailing Address - Fax:541-744-2847
Practice Address - Street 1:3030 GATEWAY STREET
Practice Address - Street 2:SEARS OPTICAL
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1027
Practice Address - Country:US
Practice Address - Phone:541-741-7049
Practice Address - Fax:541-744-2847
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2361T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000PHLCKMedicare ID - Type Unspecified
U48776Medicare UPIN