=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033210869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANG JOONG JEON MEDICAL DOCTOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 11/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10730 MAIN STREET
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-317-0020
-----------------------------------------------------
Fax | 301-317-0028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 639
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20725-0639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-317-0020
-----------------------------------------------------
Fax | 301-317-0028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 010123580
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------