Healthcare Provider Details

I. General information

NPI: 1780885491
Provider Name (Legal Business Name): EUN JI KWON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EUNJI KWON

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CRANBERRY HL STE 105
LEXINGTON MA
02421-7397
US

IV. Provider business mailing address

1 CRANBERRY HL STE 105
LEXINGTON MA
02421-7397
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-7284
  • Fax: 205-579-9387
Mailing address:
  • Phone: 800-325-7284
  • Fax: 205-579-9387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number69371
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number251783
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1017784
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number251783
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number69371
License Number StateTN
# 6
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number1017784
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: