Provider Demographics
NPI:1508234311
Name:KWON, KISEOK (DPT)
Entity Type:Individual
Prefix:DR
First Name:KISEOK
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 MCDANIEL RD APT 8306
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8646
Mailing Address - Country:US
Mailing Address - Phone:909-747-8205
Mailing Address - Fax:888-343-9937
Practice Address - Street 1:3473 SATELLITE BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8690
Practice Address - Country:US
Practice Address - Phone:909-747-8205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25657225100000X
GAPT013151225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist