Provider Demographics
NPI:1922090513
Name:BAE, SOUNGWON (DO)
Entity type:Individual
Prefix:DR
First Name:SOUNGWON
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31235
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1235
Mailing Address - Country:US
Mailing Address - Phone:520-324-4100
Mailing Address - Fax:
Practice Address - Street 1:9348 E RITA RD STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85747-6313
Practice Address - Country:US
Practice Address - Phone:520-324-4760
Practice Address - Fax:520-324-4759
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ633207Medicaid
AZ633207Medicaid
AZH52965Medicare UPIN