Provider Demographics
NPI:1679541619
Name:AHN, JAE KYUNG (DO)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:KYUNG
Last Name:AHN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 169TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-3246
Mailing Address - Country:US
Mailing Address - Phone:718-445-4974
Mailing Address - Fax:
Practice Address - Street 1:ST. BARNABAS HOSPITAL
Practice Address - Street 2:183RD STREET AND THIRD AVE.
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:718-960-9000
Practice Address - Fax:718-960-6125
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218496207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02195182Medicaid
NY02195182Medicaid
NY32V361Medicare ID - Type Unspecified