Provider Demographics
NPI:1033210869
Name:JEON, SANG JOONG (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:
First Name:SANG
Middle Name:JOONG
Last Name:JEON
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
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 639
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20725-0639
Mailing Address - Country:US
Mailing Address - Phone:301-317-0020
Mailing Address - Fax:301-317-0028
Practice Address - Street 1:10730 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:301-317-0020
Practice Address - Fax:301-317-0028
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010123580207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0007OtherBS INDIVIDUAL
DC9105OtherBS GROUP
VA112467OtherANTHEM
VA010051207Medicaid
VA112467OtherANTHEM
DC9105OtherBS GROUP
DC014065A41Medicare ID - Type UnspecifiedINDIVIDUAL
VA014065A41Medicare ID - Type UnspecifiedINDIVIDUAL