Basic Information
| Provider Information | |||||||||
| NPI: | 1093923047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | BONMYONG | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2722 MERRILEE DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984444 | ||||||||
| FaxNumber: | 7032040116 | ||||||||
| Practice Location | |||||||||
| Address1: | 2722 MERRILEE DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984444 | ||||||||
| FaxNumber: | 7032040116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101241454 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 289604ZARD | 05 | DC | MEDICAID | 540846558 | 01 | MULTIPLAN - PHCS NETWORK ONLY | OTHER | 1093923047 | 05 | VA | MEDICAID | 0131 | 01 | CAREFIRST | OTHER | 328550 | 01 | KAISER | OTHER | 3810025992 | 05 | WV | MEDICAID | 75759 | 01 | VA | AMERIGROUP | OTHER |