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General NPI Number Information
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NPI Number | 1134318447
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Entity Type | Organization
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Legal Business Name | IL S KWAK MD INC
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Dates
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Enumeration Date | 10/23/2007
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Last Update Date | 07/08/2010
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Provider Practice Location Address
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Address Line | 2222 TIMBERBROOK TRL
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City | FORT WAYNE
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State | IN
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Zip | 46845-9530
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Country | US
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Telephone | 260-637-3939
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Fax | 260-637-3939
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Provider Business Mailing Address
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Address Line | 2222 TIMBERBROOK TRL
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City | FORT WAYNE
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State | IN
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Zip | 46845
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Country | US
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Telephone | 260-637-3939
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Fax | 260-637-3939
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. IL S KWAK
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Credential | M.D
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Telephone | 260-637-3939
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 01026132A
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License Number State | IN
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