Provider Demographics
NPI:1922199058
Name:PARK, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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:PO BOX 79537
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0537
Mailing Address - Country:US
Mailing Address - Phone:703-824-3200
Mailing Address - Fax:
Practice Address - Street 1:8001 FORBES PL
Practice Address - Street 2:SUITE 103
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-2208
Practice Address - Country:US
Practice Address - Phone:703-824-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012305812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00283101OtherCOMPUTED TOMOGRAPHY ASSOCIATES, RR MEDICARE
P00284587OtherRAILROAD MEDICARE
VA008976A68Medicare PIN
DC018372A25Medicare PIN
H50569Medicare UPIN
P00283101OtherCOMPUTED TOMOGRAPHY ASSOCIATES, RR MEDICARE