Provider Demographics
NPI:1992029599
Name:KWON, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510S HEWITT ST 406
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1659
Mailing Address - Country:US
Mailing Address - Phone:646-702-7609
Mailing Address - Fax:
Practice Address - Street 1:2051 MARENGO STREET
Practice Address - Street 2:IPI, C52100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-409-7761
Practice Address - Fax:323-441-9909
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1206422086S0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program