Provider Demographics
NPI:1285011668
Name:KWON, MIRY (DO)
Entity Type:Individual
Prefix:
First Name:MIRY
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:254 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1766
Mailing Address - Country:US
Mailing Address - Phone:732-745-8600
Mailing Address - Fax:732-246-1258
Practice Address - Street 1:254 EASTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1766
Practice Address - Country:US
Practice Address - Phone:732-745-8600
Practice Address - Fax:732-246-1258
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10400400208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics