Provider Demographics
NPI:1780689042
Name:OH, CHARLES KYUMIN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:KYUMIN
Last Name:OH
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 1:2552 WALNUT AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6935
Mailing Address - Country:US
Mailing Address - Phone:714-508-1600
Mailing Address - Fax:714-665-8304
Practice Address - Street 1:2552 WALNUT AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6935
Practice Address - Country:US
Practice Address - Phone:714-508-1600
Practice Address - Fax:714-665-8304
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH58685Medicare UPIN
CAA83003Medicare ID - Type Unspecified