Provider Demographics
NPI:1578102679
Name:BAE, HEATHER (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 ORIANA RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-3733
Mailing Address - Country:US
Mailing Address - Phone:757-875-0675
Mailing Address - Fax:757-875-0695
Practice Address - Street 1:422 ORIANA RD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-3733
Practice Address - Country:US
Practice Address - Phone:757-875-0675
Practice Address - Fax:757-875-0695
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619087608Medicaid