Provider Demographics
NPI:1770896011
Name:PARK, TRACY TOM (OD)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:TOM
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:MEE LIN
Other - Last Name:TOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:12302 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1802
Mailing Address - Country:US
Mailing Address - Phone:714-590-2020
Mailing Address - Fax:714-590-2044
Practice Address - Street 1:12302 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1802
Practice Address - Country:US
Practice Address - Phone:714-590-2020
Practice Address - Fax:714-590-2044
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist