Healthcare Provider Details

I. General information

NPI: 1992150197
Provider Name (Legal Business Name): HANNAH KWAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9675 BRIGHTON WAY STE 100
BEVERLY HILLS CA
90210-5132
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90095-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-205-7310
  • Fax: 310-205-7319
Mailing address:
  • Phone: 310-301-8707
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA169315
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA169315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: