MEDICARE: JISUN YI 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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	01012488892	VA

General Provider Information

NPI Number	:	1689965683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JISUN YI MD

Provider Business Mailing Address
First Line	:	5800 MAPLEDALE PLZ
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-4535
Country	:	US
Telephone Number	:	703-670-0067
Fax Number	:	703-670-0301

Provider Business Practice Location Address
First Line	:	5800 MAPLEDALE PLZ
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-4535
Country	:	US
Telephone Number	:	703-670-0067
Fax Number	:	703-670-0301

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

Provider Enumeration Date	:	04/25/2011
Last Update Date	:	04/25/2011

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