Provider Demographics
NPI:1346446796
Name:KWON, JIN (MD)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:
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 1:811 4TH ST NW
Mailing Address - Street 2:APT#211
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-4902
Mailing Address - Country:US
Mailing Address - Phone:617-901-2353
Mailing Address - Fax:
Practice Address - Street 1:3324 CHANATE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1708
Practice Address - Country:US
Practice Address - Phone:707-576-4070
Practice Address - Fax:707-576-4087
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD79192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN