Healthcare Provider Details

I. General information

NPI: 1497783831
Provider Name (Legal Business Name): SAM SEUNGHAE AHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1082 GLENDON AVE
LOS ANGELES CA
90024-2908
US

IV. Provider business mailing address

1082 GLENDON AVE
LOS ANGELES CA
90024-2908
US

V. Phone/Fax

Practice location:
  • Phone: 310-209-2011
  • Fax: 310-209-2113
Mailing address:
  • Phone: 310-209-2011
  • Fax: 310-209-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberF1333
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: