Provider Demographics
NPI:1134708100
Name:KWON, GI RYOUNG (DPM)
Entity type:Individual
Prefix:
First Name:GI RYOUNG
Middle Name:
Last Name:KWON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 WILSHIRE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5742
Mailing Address - Country:US
Mailing Address - Phone:201-723-4661
Mailing Address - Fax:
Practice Address - Street 1:2121 WILSHIRE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5742
Practice Address - Country:US
Practice Address - Phone:201-723-4661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE6036213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery