Healthcare Provider Details

I. General information

NPI: 1477625671
Provider Name (Legal Business Name): BUENA PARK MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 BEACH BLVD SUITE 101
BUENA PARK CA
90621-2840
US

IV. Provider business mailing address

PO BOX 277
BUENA PARK CA
90621-0277
US

V. Phone/Fax

Practice location:
  • Phone: 714-994-5290
  • Fax: 714-994-8090
Mailing address:
  • Phone: 714-994-5290
  • Fax: 714-994-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA85576
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG53693
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA63728
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA061574
License Number StateCA

VIII. Authorized Official

Name: MARTIN TAEHUNG AHN
Title or Position: PRESIDENT
Credential: MD
Phone: 714-994-5290