Provider Demographics
NPI:1487995841
Name:KWAAN, JACK H M (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:H M
Last Name:KWAAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 OCANA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3221
Mailing Address - Country:US
Mailing Address - Phone:562-598-7897
Mailing Address - Fax:
Practice Address - Street 1:2141 OCANA AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3221
Practice Address - Country:US
Practice Address - Phone:562-598-7897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFE 22071208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF11643Medicare UPIN