Healthcare Provider Details

I. General information

NPI: 1467392837
Provider Name (Legal Business Name): KENNETH SEUNG BAE HAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST
LOS ANGELES CA
90089-1001
US

IV. Provider business mailing address

1200 N STATE ST
LOS ANGELES CA
90089-1001
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-9064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number20886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: