Provider Demographics
NPI:1174866859
Name:CHANG, WAN TAN (MD)
Entity Type:Individual
Prefix:
First Name:WAN TAN
Middle Name:
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 1:3808 UNION ST STE 3K
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5670
Mailing Address - Country:US
Mailing Address - Phone:718-578-1318
Mailing Address - Fax:
Practice Address - Street 1:3808 UNION ST STE 3K
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5670
Practice Address - Country:US
Practice Address - Phone:718-886-3681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036140874207Q00000X
NY285418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine