Provider Demographics
NPI:1639130925
Name:KWAN, TAK W (MD)
Entity Type:Individual
Prefix:DR
First Name:TAK
Middle Name:W
Last Name:KWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CENTRE ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4408
Mailing Address - Country:US
Mailing Address - Phone:212-334-3507
Mailing Address - Fax:212-334-4728
Practice Address - Street 1:139 CENTRE ST
Practice Address - Street 2:SUITE 307
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4408
Practice Address - Country:US
Practice Address - Phone:212-334-3507
Practice Address - Fax:212-334-4728
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168098207RA0002X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEJ461OtherMEDICARE GROUP ID #
NY01611545Medicaid
NYWEJ461OtherMEDICARE GROUP ID #
NY01611545Medicaid