Provider Demographics
NPI:1043478555
Name:KWON, YONGSOO
Entity Type:Individual
Prefix:
First Name:YONGSOO
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 GLENWOOD OAKS CT
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-6013
Mailing Address - Country:US
Mailing Address - Phone:217-337-5299
Mailing Address - Fax:
Practice Address - Street 1:1800 GLENWOOD OAKS CT
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-6013
Practice Address - Country:US
Practice Address - Phone:217-337-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-070641208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery