1215155254 NPI number — ROMY PARK O.D.

Table of content: ROMY PARK O.D. (NPI 1215155254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215155254 NPI number — ROMY PARK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
ROMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215155254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 401240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89140-1240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-641-2007
Provider Business Mailing Address Fax Number:
702-258-2006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3615 S RAINBOW BLVD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89103-1057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-641-2007
Provider Business Practice Location Address Fax Number:
702-258-2006
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  11541T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 522 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 291059 . This is a "NVA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: NV0522 . This is a "EYEMED" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 56000 . This is a "DAVIS VISION" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 1215155254 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1215155254 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 26488 . This is a "MEDICAL EYE SERVICES" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 1215155254 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35421 . This is a "AVESIS" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 26034 . This is a "SPECTERA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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