Provider Demographics
NPI:1760411813
Name:KWOK, WARREN T (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:T
Last Name:KWOK
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:8990 GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-8532
Practice Address - Country:US
Practice Address - Phone:662-893-1160
Practice Address - Fax:662-893-1166
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27217207Q00000X
MS19093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3096620Medicaid
MS00476310Medicaid
MS00476310Medicaid
TN3096620Medicaid
MS930003526Medicare PIN