Provider Demographics
NPI:1912902115
Name:PARK, BILL M (OD)
Entity type:Individual
Prefix:DR
First Name:BILL
Middle Name:M
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 S LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-1608
Mailing Address - Country:US
Mailing Address - Phone:638-844-2500
Mailing Address - Fax:630-844-2599
Practice Address - Street 1:9 S LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-1608
Practice Address - Country:US
Practice Address - Phone:638-844-2500
Practice Address - Fax:630-844-2599
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046 007008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363187524OtherCIGNA
ILK37007OtherMEDICARE PROVIDER NUMBER
IL4584027OtherBCBS PIN
IL363187524OtherAETNA
IL5534404OtherCCN PIN
IL363187524OtherPHCS PIN
IL2218742OtherFIRST HEALTH PIN
IL11437952OtherCAQH PIN
IL11437952OtherCAQH PIN
IL210181Medicare PIN
ILDG2164Medicare PIN
IL$$$$$$$$$OtherTRICARE
IL5534404OtherCCN PIN