Provider Demographics
NPI:1699982868
Name:PARK, LISA L (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:PARK
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Gender:F
Credentials:MD
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Mailing Address - Street 1:4400 UNIVERSITY DR
Mailing Address - Street 2:STUDENT UNION BUILDING 1, ROOM 2300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4422
Mailing Address - Country:US
Mailing Address - Phone:703-993-2831
Mailing Address - Fax:703-993-4365
Practice Address - Street 1:4400 UNIVERSITY DR
Practice Address - Street 2:STUDENT UNION BUILDING 1, ROOM 2300
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4422
Practice Address - Country:US
Practice Address - Phone:703-993-2831
Practice Address - Fax:703-993-4365
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2012-01-11
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Provider Licenses
StateLicense IDTaxonomies
VA01012508872080A0000X
NJ25MA086463002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine