Healthcare Provider Details

I. General information

NPI: 1003435488
Provider Name (Legal Business Name): JANE JEEHYUN KWON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 MAIN ST
BRIDGEPORT CT
06606-3618
US

IV. Provider business mailing address

3715 MAIN ST
BRIDGEPORT CT
06606-3618
US

V. Phone/Fax

Practice location:
  • Phone: 203-371-7111
  • Fax: 203-372-5636
Mailing address:
  • Phone: 203-371-7111
  • Fax: 203-372-5636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number79290
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: