Provider Demographics
NPI:1902886898
Name:LEESANG, BRIDGET JOY (OD)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:JOY
Last Name:LEESANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:22906 US HIGHWAY 281 N
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-7632
Practice Address - Country:US
Practice Address - Phone:210-495-7483
Practice Address - Fax:210-497-1206
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5136TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019416901Medicaid
TX83810EMedicare ID - Type Unspecified
TX019416901Medicaid