Provider Demographics
NPI:1366568701
Name:PARK, HERRI C (OD)
Entity type:Individual
Prefix:DR
First Name:HERRI
Middle Name:C
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 1:1 OLD ORCHARD PLAZA
Mailing Address - Street 2:OLD ORCHARD
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077
Mailing Address - Country:US
Mailing Address - Phone:847-763-5882
Mailing Address - Fax:847-763-5881
Practice Address - Street 1:5437 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2222
Practice Address - Country:US
Practice Address - Phone:773-561-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008581152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU56652Medicare UPIN
IL373960Medicare ID - Type Unspecified