Provider Demographics
NPI:1609804293
Name:PAK, WANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:
Last Name:PAK
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 1:3301 NEW MEXICO AVE NW
Mailing Address - Street 2:SUITE 226
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-3622
Mailing Address - Country:US
Mailing Address - Phone:202-244-9404
Mailing Address - Fax:202-244-9403
Practice Address - Street 1:3301 NEW MEXICO AVE NW
Practice Address - Street 2:SUITE 226
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-3622
Practice Address - Country:US
Practice Address - Phone:202-244-9404
Practice Address - Fax:202-244-9403
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCM 32178207W00000X
MDD 005640207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCM 32178OtherSTATE MEDICAL LICENSE
MDD005640OtherMARYLAND MEDICAL LICENSE
MDD005640OtherMARYLAND MEDICAL LICENSE
G72713Medicare UPIN