Provider Demographics
NPI:1528220985
Name:AHN, BONNIE SEJEONG (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:SEJEONG
Last Name:AHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 N GEORGE MASON DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3610
Mailing Address - Country:US
Mailing Address - Phone:703-558-6730
Mailing Address - Fax:
Practice Address - Street 1:1701 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3610
Practice Address - Country:US
Practice Address - Phone:703-558-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125054381207R00000X
VA01012572962085R0202X
OH35.1220002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0089451Medicaid
OH35.122000OtherLICENSE
VA0101257296OtherSTATE LICENSE
OH0089451Medicaid