Provider Demographics
NPI:1417943309
Name:KWON, CHUL SOO (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUL
Middle Name:SOO
Last Name:KWON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2908 CHAINITA CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7625
Mailing Address - Country:US
Mailing Address - Phone:443-413-6752
Mailing Address - Fax:410-465-1436
Practice Address - Street 1:711 W 40TH ST
Practice Address - Street 2:STE 406
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211
Practice Address - Country:US
Practice Address - Phone:410-235-2880
Practice Address - Fax:410-465-1436
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00189042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD790521100Medicaid
D77753Medicare UPIN
5079Medicare ID - Type Unspecified