Provider Demographics
NPI:1477625671
Name:BUENA PARK MEDICAL GROUP
Entity Type:Organization
Organization Name:BUENA PARK MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:TAEHUNG
Authorized Official - Last Name:AHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-994-5290
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-0277
Mailing Address - Country:US
Mailing Address - Phone:714-994-5290
Mailing Address - Fax:714-994-8090
Practice Address - Street 1:6301 BEACH BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2840
Practice Address - Country:US
Practice Address - Phone:714-994-5290
Practice Address - Fax:714-994-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85576207Q00000X
CAA061574207Q00000X
CAG53693207R00000X
CAA63728207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A637280Medicaid
CAGR0099930Medicaid
CA00A855760Medicaid
CA00A615740Medicaid
CA00G536930Medicaid
CA00A615740Medicaid
CAGR0099930Medicaid
CA00A855760Medicaid
CAA93247Medicare UPIN
CAWG53693LMedicare ID - Type UnspecifiedRENDERING PROVIDER ID
CAG84271Medicare UPIN
CAWA61574EMedicare ID - Type UnspecifiedRENDERING PROVIDER ID
CAWA85576BMedicare ID - Type UnspecifiedRENDERING PROVIDER ID
CA00A637280Medicaid