Provider Demographics
NPI:1124050968
Name:KWON, OKAP (MD)
Entity type:Individual
Prefix:
First Name:OKAP
Middle Name:
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 1:964 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3326
Mailing Address - Country:US
Mailing Address - Phone:330-296-3483
Mailing Address - Fax:330-296-0756
Practice Address - Street 1:964 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3326
Practice Address - Country:US
Practice Address - Phone:330-296-3483
Practice Address - Fax:330-296-0756
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040512207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0340545Medicaid
B95412Medicare UPIN
OH0340545Medicaid