Provider Demographics
NPI:1073727822
Name:KWON, TAE S (MD)
Entity Type:Individual
Prefix:DR
First Name:TAE
Middle Name:S
Last Name:KWON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:19 BROOKLINE WAY
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-4136
Mailing Address - Country:US
Mailing Address - Phone:845-634-2293
Mailing Address - Fax:
Practice Address - Street 1:110 WELLS FARM RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6740
Practice Address - Country:US
Practice Address - Phone:845-291-7553
Practice Address - Fax:845-291-7551
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1366852084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB17028Medicare UPIN