Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 043249 | CT |
N | 111NI0900X | Internist | 043249 | CT |
N | 207RG0300X | Geriatric Medicine | 043249 | CT |
NPI | 1083683320 |
---|---|
Provider Name | Soojung Kwon |
First Address | Lafayette, IN 47903-5545 |
Second Address | Lafayette, IN 47904-2477 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2006 |
Last Update Date | 05/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000001029107 | ANTHEM PROVIDER NUMBER (01) | IN |
001432492 | (05) | CT |
201373820 | (05) | IN |
I32685 | (02) | CT |