Provider Demographics
NPI:1225191505
Name:KWON, YOUNG JAE (MD)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:JAE
Last Name:KWON
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 1:1040 ELM AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3267
Mailing Address - Country:US
Mailing Address - Phone:562-435-4777
Mailing Address - Fax:562-435-3947
Practice Address - Street 1:1040 ELM AVE STE 301
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3267
Practice Address - Country:US
Practice Address - Phone:562-435-4777
Practice Address - Fax:562-435-3947
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37514208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A375140Medicaid