1811429582 NPI number — KENNETH JUNGWOOK HAN MD

Table of content: KENNETH JUNGWOOK HAN MD (NPI 1811429582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811429582 NPI number — KENNETH JUNGWOOK HAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAN
Provider First Name:
KENNETH
Provider Middle Name:
JUNGWOOK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811429582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1290 SILAS DEANE HWY
Provider Second Line Business Mailing Address:
HHC CVO ENROLLMENT STE 102, 1ST FLOOR
Provider Business Mailing Address City Name:
WETHERSFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06109-4337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-972-2990
Provider Business Mailing Address Fax Number:
860-972-7040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 LEWIS AVE STE 221
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06451-2121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-694-8550
Provider Business Practice Location Address Fax Number:
203-694-7698
Provider Enumeration Date:
03/31/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 67816 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 316328 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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