Provider Demographics
NPI:1699773275
Name:KWON, YOUNG JOE (MD)
Entity type:Individual
Prefix:
First Name:YOUNG
Middle Name:JOE
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 1:399 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4815
Mailing Address - Country:US
Mailing Address - Phone:909-882-2266
Mailing Address - Fax:909-881-7593
Practice Address - Street 1:399 E 21ST ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4815
Practice Address - Country:US
Practice Address - Phone:909-882-2266
Practice Address - Fax:909-881-7593
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA A 317482085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0063970Medicare ID - Type Unspecified
A26593Medicare UPIN