Provider Demographics
NPI:1780965327
Name:PARK, JOANN (OD)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 MONITOR LN
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3429
Mailing Address - Country:US
Mailing Address - Phone:215-850-9767
Mailing Address - Fax:
Practice Address - Street 1:8100 BOONE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:TYSONS CORNER
Practice Address - State:VA
Practice Address - Zip Code:22182-2629
Practice Address - Country:US
Practice Address - Phone:703-991-2766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist