Basic Information
| Provider Information | |||||||||
| NPI: | 1073967782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KWAK | ||||||||
| FirstName: | BYUNG | ||||||||
| MiddleName: | SAN | ||||||||
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| Credential: | M.D. | ||||||||
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| OtherLastName: | KWAK | ||||||||
| OtherFirstName: | SAN | ||||||||
| OtherMiddleName: | BYUNG | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 462 GRIDER STREET | ||||||||
| Address2: | ERIE COUNTY MEDICAL CENTER | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168984221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 462 GRIDER STREET | ||||||||
| Address2: | ERIE COUNTY MEDICAL CENTER | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168984221 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2016 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | 41865 | AL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.