Healthcare Provider Details

I. General information

NPI: 1093992570
Provider Name (Legal Business Name): ENT & ALLERGY SPECIALISTS OF VIRGINIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2008
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44320 PREMIER PLZ SUITE 110
ASHBURN VA
20147-5076
US

IV. Provider business mailing address

44320 PREMIER PLZ SUITE 110
ASHBURN VA
20147-5076
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-8727
  • Fax: 703-723-9787
Mailing address:
  • Phone: 703-723-8727
  • Fax: 703-723-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number0101242747
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number0101237837
License Number StateVA

VIII. Authorized Official

Name: DR. JAMES JAY LEE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 703-723-8727