Provider Demographics
NPI:1083761084
Name:AHN, DAVID SUNGHO (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SUNGHO
Last Name:AHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SUNGHO
Other - Middle Name:DAVID
Other - Last Name:AHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3915 LA CRESTA WAY
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2575
Mailing Address - Country:US
Mailing Address - Phone:760-987-0431
Mailing Address - Fax:
Practice Address - Street 1:19333 BEAR VALLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-5150
Practice Address - Country:US
Practice Address - Phone:760-956-8700
Practice Address - Fax:760-240-4445
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61137208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A611370Medicaid