Healthcare Provider Details

I. General information

NPI: 1114122769
Provider Name (Legal Business Name): SEONG GON BAE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SAMUEL BAE M.D.

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 W LAKE MARY BLVD STE 330
LAKE MARY FL
32746-3383
US

IV. Provider business mailing address

4106 W LAKE MARY BLVD STE 330
LAKE MARY FL
32746-3383
US

V. Phone/Fax

Practice location:
  • Phone: 407-833-9195
  • Fax:
Mailing address:
  • Phone: 407-833-9195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA123341
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME128524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: