Basic Information
| Provider Information | |||||||||
| NPI: | 1770964389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAHNG | ||||||||
| FirstName: | JIHAE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014444741 | ||||||||
| FaxNumber: | 4014444445 | ||||||||
| Practice Location | |||||||||
| Address1: | 21750 CENTER COURT DR SOUTH | ||||||||
| Address2: | SUITE 650 | ||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236288671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2015 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | LP03523 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD16308 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.