Provider Demographics
NPI:1861596447
Name:PARK, ROY EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:EDWARD
Last Name:PARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:43480 YUKON DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-6988
Mailing Address - Country:US
Mailing Address - Phone:703-724-0330
Mailing Address - Fax:703-724-0811
Practice Address - Street 1:43480 YUKON DR
Practice Address - Street 2:SUITE 214
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6984
Practice Address - Country:US
Practice Address - Phone:703-724-0330
Practice Address - Fax:703-724-0811
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010272815Medicaid
VAU86906Medicare UPIN
00X809L78Medicare PIN
VA010272815Medicaid