Provider Demographics
NPI:1134247497
Name:PARK, KONG SURK (DC)
Entity type:Individual
Prefix:DR
First Name:KONG SURK
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7023 LITTLE RIVER TPKE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-5939
Mailing Address - Country:US
Mailing Address - Phone:703-354-8686
Mailing Address - Fax:703-354-9004
Practice Address - Street 1:7023 LITTLE RIVER TPKE
Practice Address - Street 2:SUITE 330
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-5939
Practice Address - Country:US
Practice Address - Phone:703-354-8686
Practice Address - Fax:703-354-9004
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555976111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor