Provider Demographics
NPI:1790780062
Name:KWON, YOUNG-JU (MD)
Entity Type:Individual
Prefix:
First Name:YOUNG-JU
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2408
Mailing Address - Country:US
Mailing Address - Phone:718-815-1000
Mailing Address - Fax:718-815-8122
Practice Address - Street 1:1775 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-6900
Practice Address - Country:US
Practice Address - Phone:212-427-9895
Practice Address - Fax:718-815-8122
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213207174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02001590Medicaid
NYH04644Medicare UPIN