Provider Demographics
NPI:1780762245
Name:PARK, DAVID HWANTAE (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:HWANTAE
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9100 BOTTLEBRUSH LN
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4227
Mailing Address - Country:US
Mailing Address - Phone:972-401-0008
Mailing Address - Fax:972-401-1630
Practice Address - Street 1:7750 N MACARTHUR BLVD
Practice Address - Street 2:STE 180
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-7524
Practice Address - Country:US
Practice Address - Phone:972-401-0008
Practice Address - Fax:972-401-1630
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6049TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX60122914OtherDPS REGISTRATION
TXMP0787361OtherDEA
TXTXB150019Medicare PIN
TXMP0787361OtherDEA