Provider Demographics
NPI:1902865199
Name:PARK, SUE Y (MD)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:Y
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 1:1500 N BEAUREGARD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1723
Mailing Address - Country:US
Mailing Address - Phone:703-212-6600
Mailing Address - Fax:703-931-0961
Practice Address - Street 1:1500 N BEAUREGARD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1723
Practice Address - Country:US
Practice Address - Phone:703-212-6600
Practice Address - Fax:703-931-0961
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056410208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6719694Medicaid