Provider Demographics
NPI:1205833910
Name:PARK, SOO WOONG (MD)
Entity Type:Individual
Prefix:DR
First Name:SOO WOONG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SOO
Other - Middle Name:W
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10680 MAIN ST
Mailing Address - Street 2:STE 130
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-3811
Mailing Address - Country:US
Mailing Address - Phone:703-273-6802
Mailing Address - Fax:703-273-3960
Practice Address - Street 1:10680 MAIN ST
Practice Address - Street 2:STE 130
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3811
Practice Address - Country:US
Practice Address - Phone:703-273-6802
Practice Address - Fax:703-273-3960
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6075550Medicaid
VA6075550Medicaid
158580Medicare PIN