Provider Demographics
NPI:1194212894
Name:YANASE PARK, TIFFANY YUMI (OD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:YUMI
Last Name:YANASE 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 1:11370 ANDERSON ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2154
Mailing Address - Fax:
Practice Address - Street 1:11370 ANDERSON ST STE 1800
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2154
Practice Address - Fax:909-558-2180
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003393152W00000X, 152WP0200X
CA34091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics