Healthcare Provider Details

I. General information

NPI: 1265463731
Provider Name (Legal Business Name): ELISE JUNG-MIN KWON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19950 RINALDI ST
PORTER RANCH CA
91326-4141
US

IV. Provider business mailing address

PO BOX 9602
MISSION HILLS CA
91346-9602
US

V. Phone/Fax

Practice location:
  • Phone: 818-403-2420
  • Fax: 818-360-6036
Mailing address:
  • Phone: 818-837-5691
  • Fax: 818-792-4793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA83539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: