Provider Demographics
NPI:1063416394
Name:AHN, PETER BRYAN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:BRYAN
Last Name:AHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9255 ATLANTIC DR SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-8950
Mailing Address - Country:US
Mailing Address - Phone:319-396-2000
Mailing Address - Fax:319-396-5567
Practice Address - Street 1:9255 ATLANTIC DR SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-8950
Practice Address - Country:US
Practice Address - Phone:319-396-2000
Practice Address - Fax:319-396-5567
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI00121Medicare UPIN
I15470Medicare PIN
IAI11130Medicare ID - Type Unspecified
IAP00346346Medicare PIN
IA0363070001Medicare PIN