Provider Demographics
NPI:1497788848
Name:KWAK, IL-SUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:IL-SUNG
Middle Name:
Last Name:KWAK
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 1:2222 TIMBERBROOK TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9530
Mailing Address - Country:US
Mailing Address - Phone:260-637-3939
Mailing Address - Fax:
Practice Address - Street 1:2222 TIMBERBROOK TRL
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9530
Practice Address - Country:US
Practice Address - Phone:260-637-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0102632A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN058200AMedicare ID - Type Unspecified
INB28119Medicare UPIN