Provider Demographics
NPI:1174632475
Name:CHANG, MARK WAN SOO (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAN SOO
Last Name:CHANG
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 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:2428 KNOB CREEK ROAD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-282-5054
Practice Address - Fax:423-230-5097
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28931207RI0011X, 207RC0000X, 207RI0011X
VA0101059203207RI0011X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790596VMedicaid
NC89014ATMedicaid
VA005867967OtherMEDICAID OF VA
TN3373123Medicaid
TNTN0102OtherJDH
VA320332OtherANTHEM
TN4017298OtherBCBS
KY64001084Medicaid
TN3373123Medicaid
NC89014ATMedicaid
VA320332OtherANTHEM
VA005867967OtherMEDICAID OF VA
E77544Medicare UPIN
VAC08273Medicare ID - Type UnspecifiedGROUP #