Provider Demographics
NPI:1770970055
Name:KWON, MELISSA ATMADJA (MD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ATMADJA
Last Name:KWON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:LAUREN
Other - Last Name:ATMADJA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1100 VAN NESS AVE # LEVEL4
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-6978
Mailing Address - Country:US
Mailing Address - Phone:415-600-0140
Mailing Address - Fax:415-369-1362
Practice Address - Street 1:1100 VAN NESS AVE # LEVEL4
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6978
Practice Address - Country:US
Practice Address - Phone:415-600-0140
Practice Address - Fax:415-369-1362
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA145146207R00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA145146OtherSTATE MEDICAL LICENSE
CAFA6364551OtherFEDERAL DEA LICENSE