Provider Demographics
NPI:1407964315
Name:KWOK, TAI-CHI (MD)
Entity Type:Individual
Prefix:
First Name:TAI-CHI
Middle Name:
Last Name:KWOK
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 1:1761 BEALL AVE
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2342
Mailing Address - Country:US
Mailing Address - Phone:330-345-5374
Mailing Address - Fax:330-345-5814
Practice Address - Street 1:1761 BEALL AVE
Practice Address - Street 2:SUITE 3C
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2342
Practice Address - Country:US
Practice Address - Phone:330-345-5374
Practice Address - Fax:330-345-5814
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-074032207QG0300X
OH35074032207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2177059Medicaid
H19463Medicare UPIN
OH4203401Medicare PIN