Provider Demographics
NPI:1376605873
Name:PARK, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
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 1:200 N GLEBE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-3728
Mailing Address - Country:US
Mailing Address - Phone:703-243-1300
Mailing Address - Fax:703-243-1151
Practice Address - Street 1:200 N GLEBE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-3728
Practice Address - Country:US
Practice Address - Phone:703-243-1300
Practice Address - Fax:703-243-1151
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240558207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics