Provider Demographics
NPI:1720049034
Name:PARK, MARK C (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10507 ILONA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2312
Mailing Address - Country:US
Mailing Address - Phone:310-470-0848
Mailing Address - Fax:
Practice Address - Street 1:6345 BALBOA BLVD
Practice Address - Street 2:BUILDING 3, SUITE 250
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1519
Practice Address - Country:US
Practice Address - Phone:818-344-3937
Practice Address - Fax:818-344-1229
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11381T152W00000X, 152WC0802X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP11381AMedicare ID - Type Unspecified
CAW16162Medicare UPIN