Provider Demographics
NPI:1508064502
Name:EDANG, MARK ANCEL G (MD)
Entity Type:Individual
Prefix:
First Name:MARK ANCEL
Middle Name:G
Last Name:EDANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARK ANCEL
Other - Middle Name:GUERRERO
Other - Last Name:EDANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:600 GRESHAM DR FL 5
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-3198
Mailing Address - Fax:
Practice Address - Street 1:830 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3920
Practice Address - Country:US
Practice Address - Phone:757-967-8622
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA38947207R00000X, 208M00000X
VA0101254627208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist