MEDICARE: DR. JONGMYEONG LEE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01078563A	IN
2	207Q00000X	Family Medicine Physician	462485	PA
3	207Q00000X	Family Medicine Physician	0101269292	VA

General Provider Information

NPI Number	:	1811921794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONGMYEONG LEE MD

Provider Business Mailing Address
First Line	:	7501 LITTLE RIVER TPKE STE 304
Second Line	:
City	:	ANNANDALE
State	:	VA
Zip	:	22003-2923
Country	:	US
Telephone Number	:	703-965-3103
Fax Number	:	703-712-8053

Provider Business Practice Location Address
First Line	:	7501 LITTLE RIVER TPKE STE 304
Second Line	:
City	:	ANNANDALE
State	:	VA
Zip	:	22003-2923
Country	:	US
Telephone Number	:	703-965-3103
Fax Number	:	703-712-8053

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	10/13/2021

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