Provider Demographics
NPI:1326347873
Name:KWON, GRACE EUN (DO)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:EUN
Last Name:KWON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOPE DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-0221
Mailing Address - Country:US
Mailing Address - Phone:714-247-0300
Mailing Address - Fax:714-259-1598
Practice Address - Street 1:1 HOPE DR
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-0221
Practice Address - Country:US
Practice Address - Phone:714-247-0300
Practice Address - Fax:714-259-1598
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT540772084P0800X, 2084P0802X
CA20A120132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008059045OtherKWON MEDICAID
CTD400248447OtherKWON MEDICARE
CTD400248447OtherKWON MEDICARE
CT004217099OtherPCS LONG WHARF MEDICAID
CT008003745OtherACCESS CENTER MEDICAID