Provider Demographics
NPI:1134242258
Name:KANG, JEANWAN (MD)
Entity type:Individual
Prefix:
First Name:JEANWAN
Middle Name:
Last Name:KANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:29 S GREENE ST STE 319
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1504
Mailing Address - Country:US
Mailing Address - Phone:667-214-1734
Mailing Address - Fax:410-706-6976
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:667-214-1718
Practice Address - Fax:410-328-5147
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA231438208600000X
NHLT-38582086S0129X
NH183262086S0129X
OH351200232086S0129X
MDD927682086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery