Provider Demographics
NPI:1598710253
Name:KWAK, DAE T (MD)
Entity Type:Individual
Prefix:DR
First Name:DAE
Middle Name:T
Last Name:KWAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAE
Other - Middle Name:H
Other - Last Name:KWAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3860 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2460
Mailing Address - Country:US
Mailing Address - Phone:872-588-3000
Mailing Address - Fax:872-588-3021
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:872-588-3021
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101810207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK07757Medicare PIN
ILI09591Medicare UPIN