Provider Demographics
NPI:1093076945
Name:CHANG, ELISABETH JONES (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:JONES
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD BLDG 9250
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:762-408-0456
Mailing Address - Fax:
Practice Address - Street 1:7530 TERRAPIN TRL
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-7909
Practice Address - Country:US
Practice Address - Phone:623-760-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-17319207Q00000X
GA79110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN