Healthcare Provider Details

I. General information

NPI: 1609339027
Provider Name (Legal Business Name): DONG HO GWAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DAMIAN GWAK

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 W POLK ST STE 100275
CHICAGO IL
60605-2000
US

IV. Provider business mailing address

47 W POLK ST STE 100275
CHICAGO IL
60605-2000
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number13832
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number13832
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.160511
License Number StateIL
# 4
Primary TaxonomyN
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: