Provider Demographics
NPI:1063572279
Name:PARK, JONATHAN D (OD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:7457 LAS COLINAS BLVD
Practice Address - Street 2:#100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-7561
Practice Address - Country:US
Practice Address - Phone:214-382-3061
Practice Address - Fax:214-382-3071
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6272TG152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU93776Medicare UPIN
TX8D3046Medicare ID - Type UnspecifiedINDIVIDUAL