Provider Demographics
NPI:1992801740
Name:KWON, OYOON
Entity type:Individual
Prefix:MR
First Name:OYOON
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3504
Mailing Address - Country:US
Mailing Address - Phone:212-684-0090
Mailing Address - Fax:212-629-4749
Practice Address - Street 1:1257 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3504
Practice Address - Country:US
Practice Address - Phone:212-684-0090
Practice Address - Fax:212-629-4749
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00267996Medicaid