Provider Demographics
NPI:1710324660
Name:BAE, SUNGJUN (DPT)
Entity Type:Individual
Prefix:
First Name:SUNGJUN
Middle Name:
Last Name:BAE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BROADHOLLOW RD STE 316
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4901
Mailing Address - Country:US
Mailing Address - Phone:347-569-2107
Mailing Address - Fax:
Practice Address - Street 1:150 BROADHOLLOW RD STE 316
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4901
Practice Address - Country:US
Practice Address - Phone:347-569-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032544-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032544OtherLICENSE