Provider Demographics
NPI:1154843928
Name:CHANG, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8914 WATERS LN
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-4879
Mailing Address - Country:US
Mailing Address - Phone:856-673-6093
Mailing Address - Fax:
Practice Address - Street 1:1975 ALPHA DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4951
Practice Address - Country:US
Practice Address - Phone:214-294-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10702900207P00000X
390200000X
TXS8163207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ.Medicaid