Provider Demographics
NPI:1982611711
Name:KWON, KANG (MD)
Entity Type:Individual
Prefix:
First Name:KANG
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4448 OAKBRIDGE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-5484
Mailing Address - Country:US
Mailing Address - Phone:810-732-4560
Mailing Address - Fax:810-732-1177
Practice Address - Street 1:4448 OAKBRIDGE DR
Practice Address - Street 2:SUITE C
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5484
Practice Address - Country:US
Practice Address - Phone:810-732-4560
Practice Address - Fax:810-732-1177
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010410372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3181910Medicaid
MI2602534242OtherBCBSM
MI2602534242OtherBCBSM
A79506Medicare UPIN