Healthcare Provider Details

I. General information

NPI: 1184200529
Provider Name (Legal Business Name): MIKE KWON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 READE PL
POUGHKEEPSIE NY
12601-3947
US

IV. Provider business mailing address

1 COLUMBIA ST STE 302 ZUCKER SCHOOL OF MEDICINE AT HOFSTRA/NORTHWELL
POUGHKEEPSIE NY
12601-3924
US

V. Phone/Fax

Practice location:
  • Phone: 845-454-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1184200529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: