Healthcare Provider Details

I. General information

NPI: 1609804293
Provider Name (Legal Business Name): WANDA PAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 NEW MEXICO AVE NW SUITE 226
WASHINGTON DC
20016-3622
US

IV. Provider business mailing address

3301 NEW MEXICO AVE NW SUITE 226
WASHINGTON DC
20016-3622
US

V. Phone/Fax

Practice location:
  • Phone: 202-244-9404
  • Fax: 202-244-9403
Mailing address:
  • Phone: 202-244-9404
  • Fax: 202-244-9403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberM 32178
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD 005640
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: