Provider Demographics
NPI:1467625681
Name:BAEK, SANGJUN (DC)
Entity Type:Individual
Prefix:DR
First Name:SANGJUN
Middle Name:
Last Name:BAEK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 E SANDY LAKE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-3108
Mailing Address - Country:US
Mailing Address - Phone:214-412-4285
Mailing Address - Fax:972-393-1006
Practice Address - Street 1:1507 E SANDY LAKE RD STE 140
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-3108
Practice Address - Country:US
Practice Address - Phone:214-412-4285
Practice Address - Fax:972-393-1006
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011146111N00000X
TX11256111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
720409OtherOPTUM HEALTH