Basic Information
| Provider Information | |||||||||
| NPI: | 1033210869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEON | ||||||||
| FirstName: | SANG | ||||||||
| MiddleName: | JOONG | ||||||||
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| Credential: | MEDICAL DOCTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 639 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207250639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013170020 | ||||||||
| FaxNumber: | 3013170028 | ||||||||
| Practice Location | |||||||||
| Address1: | 10730 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013170020 | ||||||||
| FaxNumber: | 3013170028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 010123580 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0007 | 01 | DC | BS INDIVIDUAL | OTHER | 9105 | 01 | DC | BS GROUP | OTHER | 112467 | 01 | VA | ANTHEM | OTHER | 010051207 | 05 | VA | MEDICAID |