Provider Demographics
NPI:1639198757
Name:AHN, TAEJOON (MD)
Entity Type:Individual
Prefix:DR
First Name:TAEJOON
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:DEPT 34929
Mailing Address - Street 2:P.O. BOX 39000
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-0001
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:925-952-2850
Practice Address - Street 1:1455 MONTEGO
Practice Address - Street 2:SUITE 205
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2990
Practice Address - Country:US
Practice Address - Phone:925-939-4444
Practice Address - Fax:925-939-5010
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A670620Medicaid
CAP00055639Medicare PIN
CAH76997Medicare UPIN
CA00A670624Medicare PIN