Basic Information
| Provider Information | |||||||||
| NPI: | 1922020130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KWON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | HYUN-MI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 WESTERVELT AVE | ||||||||
| Address2: | |||||||||
| City: | TENAFLY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076702531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015682423 | ||||||||
| FaxNumber: | 7189603792 | ||||||||
| Practice Location | |||||||||
| Address1: | 4422 3RD AVE | ||||||||
| Address2: | ST. BARNABAS HOSPITAL--MILLS BUILDING--4TH FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189609331 | ||||||||
| FaxNumber: | 7189603792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 209525 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01986561 | 05 | NY | MEDICAID |