Provider Demographics
NPI:1568961035
Name:GWAK, MIJEUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:MIJEUNG
Middle Name:
Last Name:GWAK
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 1:70 HOPE AVE APT 506
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2738
Mailing Address - Country:US
Mailing Address - Phone:617-999-5292
Mailing Address - Fax:
Practice Address - Street 1:88 OLYMPIC-RO, 43-GIL, SONGPA-GU
Practice Address - Street 2:DEPT. OF ANESTHESIOLOGY, ASAN MEDICAL CENTER
Practice Address - City:SEOUL
Practice Address - State:SEOUL
Practice Address - Zip Code:05505
Practice Address - Country:KR
Practice Address - Phone:617-999-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14155207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty