Provider Demographics
NPI:1194952705
Name:LEE, JESSICA GULLUNG (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:GULLUNG
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GULLUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2295 HENRY TECKLENBURG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7801
Mailing Address - Country:US
Mailing Address - Phone:843-766-7103
Mailing Address - Fax:843-763-3834
Practice Address - Street 1:2295 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-7801
Practice Address - Country:US
Practice Address - Phone:843-766-7103
Practice Address - Fax:843-763-3834
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD31770207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC48325449Medicare PIN
SCSC48325281Medicare PIN