Provider Demographics
NPI:1124033097
Name:BAEK, PETER SUNG JAE (M D)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:SUNG JAE
Last Name:BAEK
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:469-291-3369
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-648-6409
Practice Address - Fax:214-648-5461
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2546208VP0000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S7545OtherBLUE CROSS
TX179289701Medicaid
TX179289702Medicaid
TX8G4521Medicare PIN
TX8G4519Medicare PIN
TX179289702Medicaid