Healthcare Provider Details

I. General information

NPI: 1316409246
Provider Name (Legal Business Name): OHMIN KWON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5652 E BASELINE RD
MESA AZ
85206-4713
US

IV. Provider business mailing address

600 NORTH WOLFE ST PHIPPS 160
BALTIMORE MD
21287
US

V. Phone/Fax

Practice location:
  • Phone: 310-970-4481
  • Fax: 948-356-8192
Mailing address:
  • Phone: 410-502-2447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number67157
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: