Provider Demographics
NPI:1811198989
Name:LOUDOUN EYE ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:LOUDOUN EYE ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-724-0330
Mailing Address - Street 1:43480 YUKON DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-6984
Mailing Address - Country:US
Mailing Address - Phone:703-724-0330
Mailing Address - Fax:703-724-0811
Practice Address - Street 1:43480 YUKON DR
Practice Address - Street 2:SUITE 214
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6984
Practice Address - Country:US
Practice Address - Phone:703-724-0330
Practice Address - Fax:703-724-0811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010272815Medicaid
VAU86906Medicare UPIN
VA722841Medicare ID - Type Unspecified
VA010272815Medicaid