Healthcare Provider Details

I. General information

NPI: 1548477631
Provider Name (Legal Business Name): MICHAEL SOON IL KWON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 CHILDRENS WAY
SAN DIEGO CA
92123-4232
US

IV. Provider business mailing address

3020 CHILDRENS WAY # MC5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-6789
  • Fax:
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberC199378
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD441573
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberC199378
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: