Provider Demographics
NPI:1699045229
Name:CHARLES C. KWAK, MD, PLLC
Entity Type:Organization
Organization Name:CHARLES C. KWAK, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:KWAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-460-1639
Mailing Address - Street 1:3420 PARSONS BLVD
Mailing Address - Street 2:LF
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3420 PARSONS BLVD
Practice Address - Street 2:LF
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4622
Practice Address - Country:US
Practice Address - Phone:718-460-1639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218069207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty