Provider Demographics
NPI:1356327019
Name:KWON, TAI H (MD)
Entity Type:Individual
Prefix:
First Name:TAI
Middle Name:H
Last Name:KWON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24197207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30416400Medicaid
WIP00064340OtherRAILROAD MEDICARE
WI000616260Medicare ID - Type Unspecified
WI000822285Medicare ID - Type Unspecified
WIP00064340OtherRAILROAD MEDICARE