Healthcare Provider Details

I. General information

NPI: 1700895885
Provider Name (Legal Business Name): KONG YOUNG KWON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2006
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 KOLBE RD
LORAIN OH
44053-1611
US

IV. Provider business mailing address

578 N LEAVITT RD C/O MMS
AMHERST OH
44001-1131
US

V. Phone/Fax

Practice location:
  • Phone: 440-960-4000
  • Fax:
Mailing address:
  • Phone: 440-988-1009
  • Fax: 440-988-1225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.037196
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: