Provider Demographics
NPI:1336700400
Name:BAE, DAM
Entity Type:Individual
Prefix:
First Name:DAM
Middle Name:
Last Name:BAE
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 1:601 LUTHER ST W APT 1623
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2797
Mailing Address - Country:US
Mailing Address - Phone:319-621-1940
Mailing Address - Fax:
Practice Address - Street 1:601 LUTHER ST W APT 1623
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-2797
Practice Address - Country:US
Practice Address - Phone:319-621-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer