Provider Demographics
NPI:1215155254
Name:PARK, ROMY (OD)
Entity type:Individual
Prefix:
First Name:ROMY
Middle Name:
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:PO BOX 401240
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89140-1240
Mailing Address - Country:US
Mailing Address - Phone:702-641-2007
Mailing Address - Fax:702-258-2006
Practice Address - Street 1:3615 S RAINBOW BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-1057
Practice Address - Country:US
Practice Address - Phone:702-641-2007
Practice Address - Fax:702-258-2006
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11541T152W00000X
NV522152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV0522OtherEYEMED
1215155254OtherEYEMED
NV35421OtherAVESIS
1215155254OtherAETNA
NV26488OtherMEDICAL EYE SERVICES
NV56000OtherDAVIS VISION
NV291059OtherNVA
NV26034OtherSPECTERA
1215155254OtherUNITED HEALTHCARE
NV291059OtherNVA
NV26488OtherMEDICAL EYE SERVICES