Provider Demographics
NPI:1609888072
Name:HAN, SOO W (MD)
Entity Type:Individual
Prefix:DR
First Name:SOO
Middle Name:W
Last Name:HAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4228 WISCONSIN AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-2138
Mailing Address - Country:US
Mailing Address - Phone:202-885-5600
Mailing Address - Fax:
Practice Address - Street 1:1952 GALLOWS RD STE 210
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3823
Practice Address - Country:US
Practice Address - Phone:703-761-2225
Practice Address - Fax:703-761-2227
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD258512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD189231202Medicaid
DC011671500Medicaid
093735P23Medicare ID - Type Unspecified
MD189231202Medicaid