Healthcare Provider Details

I. General information

NPI: 1760301212
Provider Name (Legal Business Name): SEONGWON JEON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 FRANKLIN ST STE 1
WATERBURY CT
06706-1281
US

IV. Provider business mailing address

106 STONEBRIDGE CT APT 4108
CHESHIRE CT
06410-5408
US

V. Phone/Fax

Practice location:
  • Phone: 203-709-6424
  • Fax:
Mailing address:
  • Phone: 248-250-0336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: