Provider Demographics
NPI:1891802526
Name:KWON, SAMANTHA EILEEN (MD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:EILEEN
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 1:1500 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6504
Mailing Address - Country:US
Mailing Address - Phone:352-369-0288
Mailing Address - Fax:352-867-1053
Practice Address - Street 1:1500 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6504
Practice Address - Country:US
Practice Address - Phone:352-369-0288
Practice Address - Fax:352-867-1053
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39047208G00000X
FLME96761208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1891802526Medicaid
NC1891802526Medicaid
NCNCG6000322Medicare PIN
FL56544OtherBLUE CROSS BLUE SHIELD OF FLA
FLU8276TMedicare PIN
NC185K7OtherBCBS NC
FL276266800Medicaid
FL56544OtherBCBS
FL230482OtherAMERIGROUP
FLG85094Medicare UPIN
NC1891802526Medicaid