Provider Demographics
NPI:1679118749
Name:BAEK, MIN A (OD)
Entity Type:Individual
Prefix:
First Name:MIN A
Middle Name:
Last Name:BAEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:
Other - Last Name:BAEK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:635 SOUTH NORTON AVE. #303
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005
Mailing Address - Country:US
Mailing Address - Phone:323-899-1115
Mailing Address - Fax:
Practice Address - Street 1:4353 PARK TERRACE DR.
Practice Address - Street 2:#150
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361
Practice Address - Country:US
Practice Address - Phone:805-987-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34449TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist