Provider Demographics
NPI:1417281221
Name:JONG KOOK LEE MDPC
Entity Type:Organization
Organization Name:JONG KOOK LEE MDPC
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONG
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-256-6204
Mailing Address - Street 1:4605 PINECREST OFFICE PARK DR
Mailing Address - Street 2:A
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-1442
Mailing Address - Country:US
Mailing Address - Phone:703-256-6204
Mailing Address - Fax:703-642-9034
Practice Address - Street 1:4605 PINECREST OFFICE PARK DR
Practice Address - Street 2:A
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-1442
Practice Address - Country:US
Practice Address - Phone:703-256-6204
Practice Address - Fax:703-642-9034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5699797Medicaid
VA5699797Medicaid