Provider Demographics
NPI:1003899279
Name:CHANG, MYO SWE (MD)
Entity Type:Individual
Prefix:DR
First Name:MYO
Middle Name:SWE
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2359 FAIRVIEW PL
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-8631
Mailing Address - Country:US
Mailing Address - Phone:707-399-0780
Mailing Address - Fax:
Practice Address - Street 1:103 BODIN CIR
Practice Address - Street 2:BLD 778
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94535-1801
Practice Address - Country:US
Practice Address - Phone:707-437-1817
Practice Address - Fax:707-437-1809
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG43530Medicare UPIN
CA00A548690Medicare ID - Type Unspecified