1235127150 NPI number — HAN KYO K CHANG M.D

Table of content: HAN KYO K CHANG M.D (NPI 1235127150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235127150 NPI number — HAN KYO K CHANG M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANG
Provider First Name:
HAN KYO
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

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:
1235127150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1434 STANLEY DOLLAR DR
Provider Second Line Business Mailing Address:
UNIT 3B
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-418-4665
Provider Business Mailing Address Fax Number:
925-954-8696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1434 STANLEY DOLLAR DR
Provider Second Line Business Practice Location Address:
UNIT 3B
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-418-4665
Provider Business Practice Location Address Fax Number:
925-954-8696
Provider Enumeration Date:
10/13/2005

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: 174400000X , with the licence number:  125005 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: C138034 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5071127 . This is a "COMM BLUE/BC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00010028501 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0400458 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00602837 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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