Provider Demographics
NPI:1306109442
Name:PARK, CHELSIA (OD)
Entity type:Individual
Prefix:
First Name:CHELSIA
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 PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7160
Mailing Address - Fax:
Practice Address - Street 1:HOSPITAL DRIVE OFF HIGHWAY 191
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503-8000
Practice Address - Country:US
Practice Address - Phone:928-674-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14452152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist