Healthcare Provider Details

I. General information

NPI: 1922005537
Provider Name (Legal Business Name): LINDA PARK NIMS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 03/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 CHURCH ST NW SUITE 200 C
VIENNA VA
22180-4434
US

IV. Provider business mailing address

PO BOX 79262
BALTIMORE MD
21279-0262
US

V. Phone/Fax

Practice location:
  • Phone: 703-938-5700
  • Fax: 703-938-4467
Mailing address:
  • Phone: 703-938-5700
  • Fax: 703-938-4467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number0101028419
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: