Provider Demographics
NPI:1053381251
Name:CHISAM, MARK EWING (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EWING
Last Name:CHISAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 TREYBURN DR
Practice Address - Street 2:SUITE B
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2891
Practice Address - Country:US
Practice Address - Phone:757-220-4900
Practice Address - Fax:757-565-5328
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2013-10-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA01010542002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053381251Medicaid
VAP00999262Medicare PIN
VAG32428Medicare UPIN
VA1053381251Medicaid