Provider Demographics
NPI:1740247071
Name:BACK, HAE SUN (OD)
Entity type:Individual
Prefix:
First Name:HAE
Middle Name:SUN
Last Name:BACK
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 1:275 ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3554
Mailing Address - Country:US
Mailing Address - Phone:973-489-8900
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:275 ROUTE 22
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-3554
Practice Address - Country:US
Practice Address - Phone:973-489-8900
Practice Address - Fax:210-524-6587
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00598500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0076431Medicaid
NJ0076431Medicaid
NJ093033Medicare ID - Type Unspecified