1154843928 NPI number — MICHELLE CHANG

Table of content: MICHELLE CHANG (NPI 1154843928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154843928 NPI number — MICHELLE CHANG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANG
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154843928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8914 WATERS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROWLETT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75089-4879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-673-6093
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1975 ALPHA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKWALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75087-4951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-294-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  25MA10702900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: S8163 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: . , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".