Provider Demographics
NPI:1306119680
Name:SEUNG S GWON M D INC
Entity type:Organization
Organization Name:SEUNG S GWON M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:GWON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-353-2244
Mailing Address - Street 1:1699 W MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2235
Mailing Address - Country:US
Mailing Address - Phone:760-353-2244
Mailing Address - Fax:760-353-2431
Practice Address - Street 1:1699 W MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2235
Practice Address - Country:US
Practice Address - Phone:760-353-2244
Practice Address - Fax:760-353-2431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81046208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA81046Medicare PIN