Provider Demographics
NPI:1013402718
Name:BAEK, DONGHWA
Entity type:Individual
Prefix:
First Name:DONGHWA
Middle Name:
Last Name:BAEK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4701
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4701
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-3490
Practice Address - Fax:713-793-1178
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10064572390200000X
PAMT229978390200000X
TXU1232207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program