Provider Demographics
NPI:1568514412
Name:KWAK, EDWARD S (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:S
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 1:737 PARK AVE APT 1D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4264
Mailing Address - Country:US
Mailing Address - Phone:212-229-1100
Mailing Address - Fax:212-229-1105
Practice Address - Street 1:737 PARK AVE APT 1D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4264
Practice Address - Country:US
Practice Address - Phone:212-229-1100
Practice Address - Fax:212-229-1105
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236600207YS0123X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02877961Medicaid
NY444131Medicare PIN
444131Medicare PIN