Basic Information
Provider Information | |||||||||
NPI: | 1972633741 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KWON | ||||||||
FirstName: | JEFF | ||||||||
MiddleName: | SOONCHUEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D, | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 415126 | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022410001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033843394 | ||||||||
FaxNumber: | 2033843829 | ||||||||
Practice Location | |||||||||
Address1: | 226 MILL HILL AVE | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | BRIDGEPORT | ||||||||
State: | CT | ||||||||
PostalCode: | 066102826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033843394 | ||||||||
FaxNumber: | 2033843829 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2007 | ||||||||
LastUpdateDate: | 06/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 36113651 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | 036113651 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 036116351 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 047736 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
No ID Information.