Provider Demographics
NPI:1700895885
Name:KWON, KONG YOUNG (MD)
Entity Type:Individual
Prefix:
First Name:KONG
Middle Name:YOUNG
Last Name:KWON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 N LEAVITT RD
Mailing Address - Street 2:C/O MMS
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1131
Mailing Address - Country:US
Mailing Address - Phone:440-988-1009
Mailing Address - Fax:440-988-1225
Practice Address - Street 1:3700 KOLBE RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1611
Practice Address - Country:US
Practice Address - Phone:440-960-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0371962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2689863Medicaid
OH2943917Medicaid
OH9375981Medicare PIN
OH2943917Medicaid