Healthcare Provider Details

I. General information

NPI: 1700215548
Provider Name (Legal Business Name): SEONG GON BAE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15211 VANOWEN ST UNIT 200
VAN NUYS CA
91405-3606
US

IV. Provider business mailing address

230 S JACKSON ST APT 309
GLENDALE CA
91205-1592
US

V. Phone/Fax

Practice location:
  • Phone: 818-782-3255
  • Fax: 818-782-7026
Mailing address:
  • Phone: 818-782-3255
  • Fax: 818-782-7026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA123341
License Number StateCA

VIII. Authorized Official

Name: SEONG GON BAE
Title or Position: CEO
Credential: MD
Phone: 818-782-3255