Provider Demographics
NPI:1609819614
Name:PARK, SONYA MINHA (MD)
Entity type:Individual
Prefix:
First Name:SONYA
Middle Name:MINHA
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 BLOSSOM HILL RD
Mailing Address - Street 2:STE 265
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-1652
Mailing Address - Country:US
Mailing Address - Phone:408-227-7122
Mailing Address - Fax:
Practice Address - Street 1:10300 S DE ANZA BLVD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3030
Practice Address - Country:US
Practice Address - Phone:408-252-7310
Practice Address - Fax:408-257-8355
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4527152W00000X
CAOPT14382-TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4527OtherLICENSE
CAOPT14382-TPLOtherCA LICENSE