Provider Demographics
NPI:1073967782
Name:KWAK, BYUNG SAN (MD)
Entity Type:Individual
Prefix:
First Name:BYUNG
Middle Name:SAN
Last Name:KWAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAN
Other - Middle Name:BYUNG
Other - Last Name:KWAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:462 GRIDER STREET
Mailing Address - Street 2:ERIE COUNTY MEDICAL CENTER
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215
Mailing Address - Country:US
Mailing Address - Phone:716-898-4221
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER STREET
Practice Address - Street 2:ERIE COUNTY MEDICAL CENTER
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215
Practice Address - Country:US
Practice Address - Phone:716-898-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL418652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program