Provider Demographics
NPI:1851365720
Name:LEE, JAE Y (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:Y
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 1:419 HOLIDAY COURT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186
Mailing Address - Country:US
Mailing Address - Phone:540-347-4200
Mailing Address - Fax:540-341-7054
Practice Address - Street 1:419 HOLIDAY COURT
Practice Address - Street 2:SUITE 100
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186
Practice Address - Country:US
Practice Address - Phone:540-347-4200
Practice Address - Fax:540-341-7054
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010026024Medicaid
VA00V672P79Medicare ID - Type Unspecified
VA010026024Medicaid