Healthcare Provider Details

I. General information

NPI: 1356459929
Provider Name (Legal Business Name): PETER H KWON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 CRYSTAL RUN RD SUITE 201
MIDDLETOWN NY
10941-4013
US

IV. Provider business mailing address

384 CRYSTAL RUN RD SUITE 201
MIDDLETOWN NY
10941-4013
US

V. Phone/Fax

Practice location:
  • Phone: 845-692-8780
  • Fax: 845-692-3439
Mailing address:
  • Phone: 845-692-8780
  • Fax: 845-692-3439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number216778
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number216778
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: