Provider Demographics
NPI:1528298700
Name:SANDRA S. KWAK, M.D., INC.
Entity type:Organization
Organization Name:SANDRA S. KWAK, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:SOOHYUN
Authorized Official - Last Name:KWAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-645-8800
Mailing Address - Street 1:PO BOX 28884
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2040
Mailing Address - Country:US
Mailing Address - Phone:949-665-8800
Mailing Address - Fax:949-665-8844
Practice Address - Street 1:520 SUPERIOR AVE STE 310
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3667
Practice Address - Country:US
Practice Address - Phone:949-645-8800
Practice Address - Fax:949-645-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88895207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316011364OtherINDIVIDUAL NPI NUMBER