Provider Demographics
NPI:1275681801
Name:AHN, BONG H (MD)
Entity Type:Individual
Prefix:DR
First Name:BONG
Middle Name:H
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 1:13678 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5515
Mailing Address - Country:US
Mailing Address - Phone:718-539-6600
Mailing Address - Fax:718-939-4929
Practice Address - Street 1:13678 39TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5515
Practice Address - Country:US
Practice Address - Phone:718-539-6600
Practice Address - Fax:718-939-4929
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111111-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB18342Medicare UPIN
NY82602Medicare ID - Type Unspecified