Provider Demographics
NPI:1740260041
Name:JAIN, SUSHIL K (OD)
Entity type:Individual
Prefix:DR
First Name:SUSHIL
Middle Name:K
Last Name:JAIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2543 GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:DUNN LORING
Mailing Address - State:VA
Mailing Address - Zip Code:22027-1310
Mailing Address - Country:US
Mailing Address - Phone:240-277-3039
Mailing Address - Fax:
Practice Address - Street 1:10580 ARROWHEAD DRIVE
Practice Address - Street 2:FAIRFAX HEALTH CENTER
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:571-432-2680
Practice Address - Fax:571-432-2795
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001001152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCU94503Medicare UPIN
VAC09866Medicare PIN
DCG02011Medicare PIN