Provider Demographics
NPI:1609962521
Name:FANG, CHARLIE WEICHIN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:WEICHIN
Last Name:FANG
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 1:12708 EARLY RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-6130
Mailing Address - Country:US
Mailing Address - Phone:865-310-2773
Mailing Address - Fax:
Practice Address - Street 1:13851 HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:WHITWELL
Practice Address - State:TN
Practice Address - Zip Code:37397-5373
Practice Address - Country:US
Practice Address - Phone:423-653-9210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055513207P00000X
VA0101251958207P00000X
TN38728207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3898281Medicaid
GAP00288351OtherRAILROAD
TN4087933OtherBCBSTN
TNP00231542OtherRAILROAD
GA331010801AMedicaid
KY64088644Medicaid
GA93BFBMJMedicare PIN
TN3898281Medicare PIN