Provider Demographics
NPI:1235300963
Name:FULLER, SEUNGHEE OH (MD)
Entity Type:Individual
Prefix:DR
First Name:SEUNGHEE
Middle Name:OH
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 N LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3025
Mailing Address - Country:US
Mailing Address - Phone:806-788-0040
Mailing Address - Fax:
Practice Address - Street 1:10507 QUAKER AVE
Practice Address - Street 2:UNIT A
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-8441
Practice Address - Country:US
Practice Address - Phone:806-701-5425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4635207Q00000X
ARE-6123207Q00000X
NMMD2009-0714207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX259673YLAVMedicare PIN