Provider Demographics
NPI:1932183852
Name:PARK, DOROTHY J (OD)
Entity Type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:J
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 1:1818 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3534
Mailing Address - Country:US
Mailing Address - Phone:803-254-6306
Mailing Address - Fax:803-771-6745
Practice Address - Street 1:1818 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3534
Practice Address - Country:US
Practice Address - Phone:803-254-6306
Practice Address - Fax:803-771-6745
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC858152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD08588Medicaid
SC57-1062179OtherBLUE CROSS BLUE SHIELD
SC5840Medicare UPIN