Healthcare Provider Details

I. General information

NPI: 1891802526
Provider Name (Legal Business Name): SAMANTHA EILEEN KWON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SW 1ST AVE
OCALA FL
34471-6504
US

IV. Provider business mailing address

1500 SW 1ST AVE
OCALA FL
34471-6504
US

V. Phone/Fax

Practice location:
  • Phone: 352-369-0288
  • Fax: 352-867-1053
Mailing address:
  • Phone: 352-369-0288
  • Fax: 352-867-1053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number39047
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME96761
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: