Provider Demographics
NPI:1497818025
Name:LEE, CHONG S (MD)
Entity Type:Individual
Prefix:
First Name:CHONG
Middle Name:S
Last Name:LEE
Suffix:
Gender:M
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:PO BOX 2847
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 KINGLSEY LANE SUITE 405
Practice Address - Street 2:BON SECOURS SURGICAL SPECIALISTS
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505
Practice Address - Country:US
Practice Address - Phone:757-278-2220
Practice Address - Fax:757-489-0701
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60920799208600000X
MI4301064070208C00000X
ORMD191833208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2155620Medicaid
CL064070OtherCHAMPUS-CHAMPUS
280H264470OtherBLUE CROSS-BLUE CROSS
CL064070OtherCOMMERCIAL-COMMERCIAL NUMBER
F88735Medicare UPIN
0H26447006Medicare ID - Type Unspecified