Basic Information
Provider Information | |||||||||
NPI: | 1316989288 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OH | ||||||||
FirstName: | CHANG | ||||||||
MiddleName: | KYEONG | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2544 COURT DR STE G | ||||||||
Address2: |   | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280543450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048549990 | ||||||||
FaxNumber: | 7048549045 | ||||||||
Practice Location | |||||||||
Address1: | 2544 COURT DR STE G | ||||||||
Address2: |   | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280543450 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048549990 | ||||||||
FaxNumber: | 7048549045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 01/25/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 01067834A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 2016-02536 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 000000659151 | 01 | IN | BCBS | OTHER | 200981250 | 05 | IN |   | MEDICAID |