MEDICARE: DR. MINJI GWAK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1295538072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MINJI GWAK MD

Provider Business Mailing Address
First Line	:	234 E 149TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10451-5504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 50TH AVE APT 510E
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5935
Country	:	US
Telephone Number	:	845-906-9146
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2025
Last Update Date	:	03/28/2025

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