Healthcare Provider Details

I. General information

NPI: 1366600322
Provider Name (Legal Business Name): KEN K KWOK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1384 BATTLEFIELD PKWY
FORT OGLETHORPE GA
30742-4010
US

IV. Provider business mailing address

869 TRAILSIDE LN SW
MARIETTA GA
30064-3077
US

V. Phone/Fax

Practice location:
  • Phone: 706-858-8083
  • Fax: 706-861-2745
Mailing address:
  • Phone: 770-427-0005
  • Fax: 770-427-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number22808
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: