Provider Demographics
NPI:1073247144
Name:BAEK, MOON SIK
Entity Type:Individual
Prefix:
First Name:MOON SIK
Middle Name:
Last Name:BAEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 MARROWS RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-3701
Mailing Address - Country:US
Mailing Address - Phone:302-509-8418
Mailing Address - Fax:
Practice Address - Street 1:71 MARROWS RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-3701
Practice Address - Country:US
Practice Address - Phone:302-509-8418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2022704976156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty