Provider Demographics
NPI:1326271909
Name:JANG, KWANG M (DO)
Entity Type:Individual
Prefix:
First Name:KWANG
Middle Name:M
Last Name:JANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7464 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1620
Mailing Address - Country:US
Mailing Address - Phone:773-381-8700
Mailing Address - Fax:773-381-8701
Practice Address - Street 1:7464 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1620
Practice Address - Country:US
Practice Address - Phone:773-381-8700
Practice Address - Fax:773-381-8701
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125056216207R00000X
IL036132637207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125056216OtherIL STATE LICENSE # 125056216
IL036132637OtherIL PERMANENT LICENSE