Provider Demographics
NPI:1396720454
Name:KOCHENDERFER, MARK D (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:KOCHENDERFER
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 1:2013 JEFFERSON ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-2419
Mailing Address - Country:US
Mailing Address - Phone:540-982-0237
Mailing Address - Fax:540-982-0103
Practice Address - Street 1:2013 JEFFERSON ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2419
Practice Address - Country:US
Practice Address - Phone:540-982-0237
Practice Address - Fax:540-982-0103
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244463207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396720454OtherANTHEM
VA1396720454Medicaid
I34310Medicare UPIN
VA1396720454OtherANTHEM