Basic Information
| Provider Information | |||||||||
| NPI: | 1548895055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KWON | ||||||||
| FirstName: | OCHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2211 3RD AVE APT 5C | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100353531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107070790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4422 THIRD AVE | ||||||||
| Address2: | BRAKER BUILDING, 4TH FLOOR, ROOM 405 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189609000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2020 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.