Provider Demographics
NPI:1922005537
Name:NIMS, LINDA PARK (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:PARK
Last Name:NIMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 79262
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0262
Mailing Address - Country:US
Mailing Address - Phone:703-938-5700
Mailing Address - Fax:703-938-4467
Practice Address - Street 1:243 CHURCH ST NW
Practice Address - Street 2:SUITE 200 C
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4434
Practice Address - Country:US
Practice Address - Phone:703-938-5700
Practice Address - Fax:703-938-4467
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-29
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028419207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG00477OtherGROUP MEDICARE PIN
B94249Medicare UPIN
VA00A125L77Medicare PIN