Provider Demographics
NPI:1760408470
Name:KWON, THEODORE H (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:H
Last Name:KWON
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:PO BOX 1557
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90637-1557
Mailing Address - Country:US
Mailing Address - Phone:213-300-0010
Mailing Address - Fax:714-590-0007
Practice Address - Street 1:9042 GARDEN GROVE BLVD
Practice Address - Street 2:299
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1370
Practice Address - Country:US
Practice Address - Phone:714-590-0001
Practice Address - Fax:714-590-0007
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35852207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A358520OtherMOST INSURANCE CO
CA00A358520Medicaid
CAA35852OtherMOST INSURANCE CO
CAA35852OtherMOST INSURANCE CO
CAD34056Medicare UPIN