Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DN015936 | GA |
Y | 213EG0000X | General Practice | DN015936 | GA |
NPI | 1003461559 |
---|---|
Provider Name | Dr. Euiyoung Kwak |
First Address | Smyrna, GA 30080-8975 |
Second Address | Hiram, GA 30141-2642 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2019 |
Last Update Date | 01/08/2019 |