Provider Demographics
NPI:1104981489
Name:KWON, JIYONG JENNIFER (OD)
Entity type:Individual
Prefix:DR
First Name:JIYONG
Middle Name:JENNIFER
Last Name:KWON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3903
Mailing Address - Country:US
Mailing Address - Phone:609-304-6600
Mailing Address - Fax:
Practice Address - Street 1:1734 LINCOLN HWY # 27
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-3449
Practice Address - Country:US
Practice Address - Phone:732-393-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001700152W00000X
NJ27OA005657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU71383Medicare UPIN
PA063902KKNMedicare ID - Type Unspecified
NJ066354Medicare ID - Type Unspecified
P00024001Medicare ID - Type UnspecifiedRAILROAD