Provider Demographics
NPI:1982663795
Name:AHN, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SUNG
Other - Middle Name:
Other - Last Name:AHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4620 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3102
Mailing Address - Country:US
Mailing Address - Phone:323-462-6423
Mailing Address - Fax:323-462-3904
Practice Address - Street 1:4620 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3102
Practice Address - Country:US
Practice Address - Phone:323-462-6423
Practice Address - Fax:323-462-3904
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40196174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A401960Medicaid
CA953951355OtherTAX ID #
CAA29073OtherPTAN
CAA40196Medicare PIN
CA953951355OtherTAX ID #