Provider Demographics
NPI:1003865924
Name:ISHIZAWAR, YORCKAY CHANG (MD)
Entity Type:Individual
Prefix:
First Name:YORCKAY
Middle Name:CHANG
Last Name:ISHIZAWAR
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 1:12504 NIGHTINGALE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2600
Mailing Address - Country:US
Mailing Address - Phone:804-530-3712
Mailing Address - Fax:804-530-3712
Practice Address - Street 1:211 TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2827
Practice Address - Country:US
Practice Address - Phone:804-526-0107
Practice Address - Fax:804-526-4466
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031281208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7382111Medicaid
VA7382111Medicaid