Provider Demographics
NPI:1033140793
Name:SUSHIL K JAIN OD PC
Entity Type:Organization
Organization Name:SUSHIL K JAIN OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSHIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:240-277-3039
Mailing Address - Street 1:2543 GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:DUNN LORING
Mailing Address - State:VA
Mailing Address - Zip Code:22027-1310
Mailing Address - Country:US
Mailing Address - Phone:703-525-4411
Mailing Address - Fax:703-525-0823
Practice Address - Street 1:6251 OLD DOMINION DR
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4827
Practice Address - Country:US
Practice Address - Phone:703-534-5717
Practice Address - Fax:703-534-5718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001001152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCU94503Medicare UPIN
VAC09866Medicare PIN
DCG02011Medicare PIN