Provider Demographics
NPI:1144373150
Name:PARK, JAMES K (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:K
Last Name:PARK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 JOHN MARR DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3310
Mailing Address - Country:US
Mailing Address - Phone:703-354-2200
Mailing Address - Fax:571-323-3938
Practice Address - Street 1:8330 BOONE BLVD STE 160
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2678
Practice Address - Country:US
Practice Address - Phone:703-354-2200
Practice Address - Fax:703-977-1728
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101840533207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101840533OtherSTATE MEDICAL LICENSE
DCMD32179OtherMEDICAL LICENSE NUMBER
MDD55608OtherSTATE MEDICAL LICENSE
H01295Medicare UPIN
DCMD32179OtherMEDICAL LICENSE NUMBER