Provider Demographics
NPI:1497774186
Name:LEE, JUNG SOOK (MD)
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:SOOK
Last Name:LEE
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 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1786C COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:PA
Practice Address - Zip Code:17512-9508
Practice Address - Country:US
Practice Address - Phone:717-684-3663
Practice Address - Fax:717-684-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037840L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000654210Medicaid
PAC31701Medicare UPIN
PA000654210Medicaid