Provider Demographics
NPI:1538841812
Name:PARK, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24047 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1943
Mailing Address - Country:US
Mailing Address - Phone:646-472-9816
Mailing Address - Fax:
Practice Address - Street 1:1258 6TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10020-1511
Practice Address - Country:US
Practice Address - Phone:646-789-4843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist