Provider Demographics
NPI:1114968385
Name:CHANG, JONATHAN MT (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MT
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 1:5303 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3201
Mailing Address - Country:US
Mailing Address - Phone:718-972-1777
Mailing Address - Fax:718-854-7086
Practice Address - Street 1:5303 8TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3201
Practice Address - Country:US
Practice Address - Phone:718-972-1777
Practice Address - Fax:718-854-7086
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01704241Medicaid
NY01704241Medicaid
NY650291Medicare PIN
NYG35468Medicare UPIN