Provider Demographics
NPI:1114922986
Name:CHANG, COLIN E (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:E
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 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-355-2300
Mailing Address - Fax:812-355-2316
Practice Address - Street 1:2605 E. CREEK'S EDGE DR.
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401
Practice Address - Country:US
Practice Address - Phone:812-355-2300
Practice Address - Fax:812-355-2316
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045412A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200188940Medicaid
IN200188940Medicaid
G70872Medicare UPIN
INM400021624Medicare PIN
IN200188940Medicaid