Healthcare Provider Details

I. General information

NPI: 1730115585
Provider Name (Legal Business Name): JINHEE KWAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 ROUTE 38 W
HAINESPORT NJ
08036
US

IV. Provider business mailing address

210 ARK RD
MOUNT LAUREL NJ
08054-3188
US

V. Phone/Fax

Practice location:
  • Phone: 609-261-7017
  • Fax: 609-261-4180
Mailing address:
  • Phone: 856-778-8860
  • Fax: 609-261-4180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number25MA07836000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA07836000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: