Healthcare Provider Details

I. General information

NPI: 1306848890
Provider Name (Legal Business Name): BRIAN KWON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 BORDER RD STE 300
WALTHAM MA
02451-1044
US

IV. Provider business mailing address

71 BORDER RD STE 300
WALTHAM MA
02451-1044
US

V. Phone/Fax

Practice location:
  • Phone: 781-890-2133
  • Fax: 781-890-2177
Mailing address:
  • Phone: 781-890-2133
  • Fax: 781-890-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number216761
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number216761
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: