Healthcare Provider Details

I. General information

NPI: 1730171059
Provider Name (Legal Business Name): SEUNG S. GWON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1671 W MAIN ST STE A
EL CENTRO CA
92243-5420
US

IV. Provider business mailing address

PO BOX 779
EL CENTRO CA
92244-0779
US

V. Phone/Fax

Practice location:
  • Phone: 760-353-2244
  • Fax: 760-353-2431
Mailing address:
  • Phone: 760-353-2244
  • Fax: 760-353-2431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA81046
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA81046
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: