Provider Demographics
NPI:1801942776
Name:PARK, TONY CHAN (OD)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:CHAN
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:5011 216TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BAYSIDE HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1362
Mailing Address - Country:US
Mailing Address - Phone:510-366-3506
Mailing Address - Fax:510-745-9022
Practice Address - Street 1:61-35 JUNCTION BLVD
Practice Address - Street 2:COSTCO OPTOMETRY
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2771
Practice Address - Country:US
Practice Address - Phone:718-760-7862
Practice Address - Fax:718-760-7861
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2018-03-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY007776152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG10008926Medicare PIN
CADG641AMedicare PIN