Provider Demographics
NPI:1326257213
Name:KWON, JUNGHO LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JUNGHO
Middle Name:LEE
Last Name:KWON
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 1:2825 LIVERNOIS RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1214
Mailing Address - Country:US
Mailing Address - Phone:248-689-7428
Mailing Address - Fax:
Practice Address - Street 1:2825 LIVERNOIS RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1214
Practice Address - Country:US
Practice Address - Phone:248-689-7428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083389207N00000X
TXN2611207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH54E - 8L23070Medicare UPIN
TXC458 - 8L23069Medicare PIN
TX872T - 8L23071Medicare UPIN