Provider Demographics
NPI:1114594181
Name:CHANG, KEVIN J
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:CHANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ROBERT CIR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3828
Mailing Address - Country:US
Mailing Address - Phone:516-281-4005
Mailing Address - Fax:
Practice Address - Street 1:1805 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1761
Practice Address - Country:US
Practice Address - Phone:516-281-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist