Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 6272TG | TX |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 6272TG | TX |
NPI | 1063572279 |
---|---|
Provider Name | Jonathan D Park |
First Address | Irving, TX 75063-7561 |
Second Address | Irving, TX 75063-7561 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2006 |
Last Update Date | 28/04/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U93776 | (02) | TX |