Provider Demographics
NPI:1568758399
Name:LEE, RYUN JONG (DO)
Entity Type:Individual
Prefix:
First Name:RYUN
Middle Name:JONG
Last Name:LEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12158 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1932
Mailing Address - Country:US
Mailing Address - Phone:301-430-2070
Mailing Address - Fax:301-430-2751
Practice Address - Street 1:12158 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-1932
Practice Address - Country:US
Practice Address - Phone:301-430-2070
Practice Address - Fax:301-430-2751
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203509207Q00000X
MDH81446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine