Provider Demographics
NPI:1023008117
Name:CHANG, BENJAMIN BANSUN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BANSUN
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:570-326-8723
Mailing Address - Fax:
Practice Address - Street 1:740 HIGH ST STE 2001
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3102
Practice Address - Country:US
Practice Address - Phone:703-212-8055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16976662085R0204X
NY1697662086S0129X, 208G00000X
PAMD4762462086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01022251Medicaid
NY01022251Medicaid
C59416Medicare UPIN
NYRA0781Medicare ID - Type Unspecified