Provider Demographics
NPI:1073892477
Name:AHN, SANGMIN (MD)
Entity Type:Individual
Prefix:
First Name:SANGMIN
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 WHIPPLE RD
Mailing Address - Street 2:BUILDING B, 2ND FLOOR
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1507
Mailing Address - Country:US
Mailing Address - Phone:510-675-3414
Mailing Address - Fax:510-675-3204
Practice Address - Street 1:3555 WHIPPLE RD
Practice Address - Street 2:BUILDING B, 2ND FLOOR
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1507
Practice Address - Country:US
Practice Address - Phone:510-675-3414
Practice Address - Fax:510-675-3204
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA141480208100000X
MO20110303792081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073892477Medicaid