Provider Demographics
NPI:1689602583
Name:LEE, BYUNG-BOONG
Entity Type:Individual
Prefix:
First Name:BYUNG-BOONG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
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 631856
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1830 TOWN CENTER DR
Practice Address - Street 2:SUITE 420
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3292
Practice Address - Country:US
Practice Address - Phone:703-880-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010236172086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC019258M65Medicare ID - Type Unspecified
C62410Medicare UPIN