Provider Demographics
NPI:1114701919
Name:BAE, EUNG JIN BRENDON (OD)
Entity Type:Individual
Prefix:
First Name:EUNG JIN
Middle Name:BRENDON
Last Name:BAE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9620 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6625
Mailing Address - Country:US
Mailing Address - Phone:718-793-2020
Mailing Address - Fax:718-793-2022
Practice Address - Street 1:9620 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6625
Practice Address - Country:US
Practice Address - Phone:718-793-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRT009885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist