Healthcare Provider Details

I. General information

NPI: 1669460598
Provider Name (Legal Business Name): CHUL K KWAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST 1ST FL PARK AVENUE PAVILLON
PHILADELPHIA PA
19140
US

IV. Provider business mailing address

PO BOX 827783
PHILADELPHIA PA
19182-7783
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-7237
  • Fax: 215-707-9389
Mailing address:
  • Phone: 215-707-7237
  • Fax: 215-707-9389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD032188L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: