Provider Demographics
NPI:1699026740
Name:KWON, MINJI (MD, LAC)
Entity Type:Individual
Prefix:
First Name:MINJI
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:MD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 MARTIN CT APT 531
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-2572
Mailing Address - Country:US
Mailing Address - Phone:619-410-7478
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST BOX# 432
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:619-410-7478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15028171100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171100000XOther Service ProvidersAcupuncturist