Provider Demographics
NPI:1629280169
Name:KWON MD, INC
Entity Type:Organization
Organization Name:KWON MD, INC
Other - Org Name:DERMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-706-9300
Mailing Address - Street 1:16515 S. 40TH STREET
Mailing Address - Street 2:SUITE 135
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048
Mailing Address - Country:US
Mailing Address - Phone:480-706-9300
Mailing Address - Fax:480-706-9301
Practice Address - Street 1:16515 S. 40TH STREET
Practice Address - Street 2:SUITE 135
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048
Practice Address - Country:US
Practice Address - Phone:480-706-9300
Practice Address - Fax:480-706-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28252174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ78222Medicare UPIN