Healthcare Provider Details

I. General information

NPI: 1003669201
Provider Name (Legal Business Name): ANDIE KWON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST
LOS ANGELES CA
90089-1001
US

IV. Provider business mailing address

1200 N STATE ST
LOS ANGELES CA
90089-1001
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-3360
  • Fax: 323-226-2654
Mailing address:
  • Phone: 323-409-3360
  • Fax: 323-226-2654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.083233
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA203474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: