Individual
DR. SU MIN KO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
11166 FAIRFAX BLVD, SUITE 105, FAIRFAX, VA 22030-5017
(703) 277-3360
(703) 277-3370
Mailing address
11166 FAIRFAX BLVD, SUITE 105, FAIRFAX, VA 22030-5017
(703) 277-3360
(703) 277-3370
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
2009001606
MO
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
0101250991
VA
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
2009001606
MO
208VP0014X
Interventional Pain Medicine Physician
Primary
0101250991
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000640716
BCBS
MO
05
—
1336375450
—
MO
01
—
2009001606
MEDICAL LICENSE
MO
01
—
9496409
AETNA
MO
01
—
98246
HCUSA
MO
Enumeration date
06/03/2009
Last updated
02/20/2017
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