Healthcare Provider Details

I. General information

NPI: 1558913277
Provider Name (Legal Business Name): CHRISTINE BAE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 TYSONS CORNER CTR
MC LEAN VA
22102-4525
US

IV. Provider business mailing address

902 CENTRILLION DR
MC LEAN VA
22102-1442
US

V. Phone/Fax

Practice location:
  • Phone: 703-734-0977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001234
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: