Provider Demographics
NPI:1770678823
Name:SIRIPRAKORN, PRACHAK T (MD)
Entity Type:Individual
Prefix:DR
First Name:PRACHAK
Middle Name:T
Last Name:SIRIPRAKORN
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:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-0309
Mailing Address - Country:US
Mailing Address - Phone:703-491-2179
Mailing Address - Fax:
Practice Address - Street 1:1966 OPITZ BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3304
Practice Address - Country:US
Practice Address - Phone:703-491-2179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042285174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006000193Medicaid
VA006000193Medicaid
VA110005983Medicare ID - Type Unspecified
VAB59667Medicare UPIN
VA438917Medicare Oscar/Certification