Provider Demographics
NPI:1669720017
Name:AHN, JIN (DO)
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:1701 W. CURTIS RD
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9678
Practice Address - Country:US
Practice Address - Phone:217-365-6201
Practice Address - Fax:217-326-4003
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.062482207Q00000X
IL036137206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine