Provider Demographics
NPI:1487622262
Name:CHANG, CAROL SOO-JUNG (MD)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:SOO-JUNG
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:CAROL
Other - Middle Name:SOO-JUNG
Other - Last Name:PAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2855 CHERRY BRANCH LN
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3610
Practice Address - Country:US
Practice Address - Phone:703-955-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239515207RN0300X
VAVA0101239515207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I48396Medicare UPIN