Provider Demographics
NPI:1164743308
Name:CHANG, LISA (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-2908
Mailing Address - Country:US
Mailing Address - Phone:718-204-9886
Mailing Address - Fax:
Practice Address - Street 1:4101 30TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-2908
Practice Address - Country:US
Practice Address - Phone:718-204-9886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine