Provider Demographics
NPI:1265595482
Name:DOD
Entity type:Organization
Organization Name:DOD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KYUNG
Authorized Official - Middle Name:OK
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:703-805-0067
Mailing Address - Street 1:8637 HILLSIDE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2240
Mailing Address - Country:US
Mailing Address - Phone:703-752-1776
Mailing Address - Fax:
Practice Address - Street 1:9501 FARRELL RD
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5901
Practice Address - Country:US
Practice Address - Phone:703-805-0067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001109410163WX0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WX0003XNursing Service ProvidersRegistered NurseObstetric, InpatientGroup - Multi-Specialty