Healthcare Provider Details

I. General information

NPI: 1609962521
Provider Name (Legal Business Name): CHARLIE WEICHIN FANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13851 HIGHWAY 28
WHITWELL TN
37397-5373
US

IV. Provider business mailing address

12708 EARLY RD
KNOXVILLE TN
37922-6130
US

V. Phone/Fax

Practice location:
  • Phone: 423-653-9210
  • Fax:
Mailing address:
  • Phone: 865-310-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number055513
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101251958
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number38728
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38728
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: