Provider Demographics
NPI:1245230861
Name:BAE, PETER S (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
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 1:103 W KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3902
Mailing Address - Country:US
Mailing Address - Phone:718-432-5555
Mailing Address - Fax:718-548-2399
Practice Address - Street 1:103 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3902
Practice Address - Country:US
Practice Address - Phone:718-432-5555
Practice Address - Fax:718-548-2399
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT006341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC207F1Medicare ID - Type Unspecified
NYU91097Medicare UPIN