Provider Demographics
NPI:1508231044
Name:BAE, TAE H (DO)
Entity Type:Individual
Prefix:MR
First Name:TAE
Middle Name:H
Last Name:BAE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:T
Other - Last Name:BAE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:8718 S TACOMA WAY STE C
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-4597
Mailing Address - Country:US
Mailing Address - Phone:253-301-2358
Mailing Address - Fax:
Practice Address - Street 1:8718 S TACOMA WAY STE C
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4597
Practice Address - Country:US
Practice Address - Phone:253-301-2358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO 00002034156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADO 00002034OtherOPTICIAN DISPENSING LICENSE