1699982868 NPI number — DR. LISA L PARK MD

Table of content: DR. LISA L PARK MD (NPI 1699982868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699982868 NPI number — DR. LISA L PARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
LISA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699982868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 UNIVERSITY DR
Provider Second Line Business Mailing Address:
STUDENT UNION BUILDING 1, ROOM 2300
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-4422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-993-2831
Provider Business Mailing Address Fax Number:
703-993-4365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 UNIVERSITY DR
Provider Second Line Business Practice Location Address:
STUDENT UNION BUILDING 1, ROOM 2300
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-4422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-993-2831
Provider Business Practice Location Address Fax Number:
703-993-4365
Provider Enumeration Date:
05/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  0101250887 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080A0000X , with the licence number: 25MA08646300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)