Healthcare Provider Details

I. General information

NPI: 1205846680
Provider Name (Legal Business Name): KI SOO HWANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 VALLEY RD 2ND FLOOR
WAYNE NJ
07470-3534
US

IV. Provider business mailing address

504 VALLEY RD 2ND FLOOR
WAYNE NJ
07470-3534
US

V. Phone/Fax

Practice location:
  • Phone: 973-686-0700
  • Fax: 973-686-0701
Mailing address:
  • Phone: 973-686-0700
  • Fax: 973-686-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number240401
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: