Basic Information
| Provider Information | |||||||||
| NPI: | 1497783831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AHN | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | SEUNGHAE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1082 GLENDON AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900242908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102092011 | ||||||||
| FaxNumber: | 3102092113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1082 GLENDON AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900242908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102092011 | ||||||||
| FaxNumber: | 3102092113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 01/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | F1333 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8AD481 | 01 | TX | BLUE CROSS PPO | OTHER | P00429299 | 01 | TX | RAILROAD MEDICARE | OTHER | 208087232 | 01 | TX | TRICARE/CHAMPUS | OTHER | 182297503 | 05 | TX | MEDICAID |