Provider Demographics
NPI:1144253030
Name:PARK, LORIN B (OD)
Entity type:Individual
Prefix:DR
First Name:LORIN
Middle Name:B
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:L
Other - Middle Name:BRENDT
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:5204 MATIA LN
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-7888
Mailing Address - Country:US
Mailing Address - Phone:509-542-1151
Mailing Address - Fax:
Practice Address - Street 1:4820 N ROAD 68
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9009
Practice Address - Country:US
Practice Address - Phone:509-543-7953
Practice Address - Fax:509-543-7955
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1016TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T02372Medicare UPIN