Provider Demographics
NPI:1144061714
Name:BAEK, KEN
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:
Last Name:BAEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 MONTGOMERY BLVD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3800
Mailing Address - Country:US
Mailing Address - Phone:505-828-0828
Mailing Address - Fax:
Practice Address - Street 1:10701 MONTGOMERY BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3800
Practice Address - Country:US
Practice Address - Phone:505-828-0828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0004065152W00000X
VT030.0134003152W00000X
NMOPT-2024-0010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist