Healthcare Provider Details

I. General information

NPI: 1225191505
Provider Name (Legal Business Name): YOUNG JAE KWON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 ELM AVE STE 301
LONG BEACH CA
90813-3267
US

IV. Provider business mailing address

1040 ELM AVE STE 301
LONG BEACH CA
90813-3267
US

V. Phone/Fax

Practice location:
  • Phone: 562-435-4777
  • Fax: 562-435-3947
Mailing address:
  • Phone: 562-435-4777
  • Fax: 562-435-3947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA37514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: