Provider Demographics
NPI:1689663379
Name:KWON, CHUNGDUCK STEPHAN (MD)
Entity Type:Individual
Prefix:
First Name:CHUNGDUCK STEPHAN
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C STEPHAN
Other - Middle Name:
Other - Last Name:KWON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:755 NARROWS RD N
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1548
Mailing Address - Country:US
Mailing Address - Phone:718-815-2393
Mailing Address - Fax:646-935-1916
Practice Address - Street 1:755 NARROWS RD N APT 1207
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1546
Practice Address - Country:US
Practice Address - Phone:718-815-2393
Practice Address - Fax:646-935-1916
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112120207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10L561Medicare ID - Type Unspecified
NYD39061Medicare UPIN