Provider Demographics
NPI:1316989288
Name:OH, CHANG KYEONG (MD)
Entity type:Individual
Prefix:
First Name:CHANG
Middle Name:KYEONG
Last Name:OH
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 1:2544 COURT DR STE G
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3450
Mailing Address - Country:US
Mailing Address - Phone:704-854-9990
Mailing Address - Fax:704-854-9045
Practice Address - Street 1:2544 COURT DR STE G
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3450
Practice Address - Country:US
Practice Address - Phone:704-854-9990
Practice Address - Fax:704-854-9045
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067834A207RG0100X
NC2016-02536207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000659151OtherBCBS
IN200981250Medicaid
IN200981250Medicaid