Provider Demographics
NPI:1629129887
Name:KWON, JAKE S (DPM)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:S
Last Name:KWON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:53 KNOLLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1323
Mailing Address - Country:US
Mailing Address - Phone:646-389-6485
Mailing Address - Fax:718-939-9865
Practice Address - Street 1:4232 FRANCIS LEWIS BLVD # C
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2561
Practice Address - Country:US
Practice Address - Phone:646-389-6485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD002511213ES0103X
NYN005468213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery