Provider Demographics
NPI:1093923047
Name:LEE, BONMYONG (MD)
Entity Type:Individual
Prefix:
First Name:BONMYONG
Middle Name:
Last Name:LEE
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 1:2722 MERRILEE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4400
Mailing Address - Country:US
Mailing Address - Phone:703-698-4444
Mailing Address - Fax:703-204-0116
Practice Address - Street 1:2722 MERRILEE DR STE 230
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4400
Practice Address - Country:US
Practice Address - Phone:703-698-4444
Practice Address - Fax:703-204-0116
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012414542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC289604ZARDMedicaid
540846558OtherMULTIPLAN - PHCS NETWORK ONLY
VA1093923047Medicaid
0131OtherCAREFIRST
328550OtherKAISER
WV3810025992Medicaid
VA75759OtherAMERIGROUP
0131OtherCAREFIRST