Provider Demographics
NPI:1235547662
Name:KWAK, SOON (MD)
Entity Type:Individual
Prefix:
First Name:SOON
Middle Name:
Last Name:KWAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WEST ST
Mailing Address - Street 2:UNIT 4I
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-1970
Mailing Address - Country:US
Mailing Address - Phone:917-588-1505
Mailing Address - Fax:
Practice Address - Street 1:806 TEAKWOOD RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-1330
Practice Address - Country:US
Practice Address - Phone:310-476-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29868208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice