Provider Demographics
NPI:1750331526
Name:BAE, STEVEN SUK BONG (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:SUK BONG
Last Name:BAE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 S WESTERN AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2680
Mailing Address - Country:US
Mailing Address - Phone:323-998-0080
Mailing Address - Fax:323-857-1001
Practice Address - Street 1:1110 S WESTERN AVE STE 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2680
Practice Address - Country:US
Practice Address - Phone:323-998-0080
Practice Address - Fax:323-857-1001
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11602T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU88742Medicare UPIN
CAOP11602Medicare ID - Type Unspecified