Provider Demographics
NPI:1932290376
Name:LEE, BRENT R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:R
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:4320 SEMINARY RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1535
Practice Address - Country:US
Practice Address - Phone:703-504-4270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232682207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA493812OtherNCPPO
VA219815OtherANTHEM
VA297893OtherAMERIGROUP
VA050086420OtherRAILROAD MEDICARE
VA1932290376Medicaid
VAK142-0001OtherCARE FIRST 2005
VA050086420OtherRAILROAD MEDICARE
VA009401F81Medicare ID - Type Unspecified
VA1932290376Medicaid