Provider Demographics
NPI:1467668111
Name:KWAK, MELISSA N (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:N
Last Name:KWAK
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 1:76 W COUNTRYSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-1967
Mailing Address - Country:US
Mailing Address - Phone:630-553-2722
Mailing Address - Fax:
Practice Address - Street 1:76 W COUNTRYSIDE PKWY
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1967
Practice Address - Country:US
Practice Address - Phone:630-553-2722
Practice Address - Fax:630-553-3983
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125049891390200000X
IL036.120260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program