Healthcare Provider Details

I. General information

NPI: 1093166795
Provider Name (Legal Business Name): TERRIE SUSIE AHN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 16TH ST
SANTA MONICA CA
90404-1235
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-481-4646
  • Fax: 310-899-7599
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA162214
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA162214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: