Basic Information
| Provider Information | |||||||||
| NPI: | 1003835091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMIDA | ||||||||
| FirstName: | NITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PARKWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232251223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049154607 | ||||||||
| FaxNumber: | 8049681803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1760 OLD MEADOW ROAD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | MCLEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221022210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038105217 | ||||||||
| FaxNumber: | 7032887892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101235316 | VA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 9371416 | 01 | PHCS PROVIDER NUMBER | OTHER | K169-0001 | 01 | CAREFIRST PROVIDER NUMBER | OTHER | 33225 | 01 | KY | KY MEDICAL LICENSE NUMBER | OTHER | 169355 | 01 | VA | ANTHEM | OTHER | 200100613 | 01 | NC | NC MEDICAL LICENSE NUMBER | OTHER | BD5410472 | 01 | DEA LICENSE NUMBER | OTHER | 633048 | 01 | NCPPO PROVIDER NUMBER | OTHER | 7233026 | 01 | AETNA PROVIDER NUMBER | OTHER | 0101235316 | 01 | VA | VA MEDICAL LICENSE NUMBER | OTHER | 5456737 | 01 | CIGNA PROVIDER NUMBER | OTHER |