Provider Demographics
NPI:1629004577
Name:KWON, NANCY (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:KWON
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-4090
Mailing Address - Fax:
Practice Address - Street 1:33 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3489
Practice Address - Country:US
Practice Address - Phone:631-444-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT005664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02139619Medicaid
NYC008J1OtherEMPIRE BC.BS
NY7381201OtherAETNA
NY02139619Medicaid
NY7381201OtherAETNA