Provider Demographics
NPI:1235127150
Name:CHANG, HAN KYO K (MD)
Entity Type:Individual
Prefix:
First Name:HAN KYO
Middle Name:K
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 1:1434 STANLEY DOLLAR DR
Mailing Address - Street 2:UNIT 3B
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595
Mailing Address - Country:US
Mailing Address - Phone:716-418-4665
Mailing Address - Fax:925-954-8696
Practice Address - Street 1:1434 STANLEY DOLLAR DR
Practice Address - Street 2:UNIT 3B
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595
Practice Address - Country:US
Practice Address - Phone:716-418-4665
Practice Address - Fax:925-954-8696
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125005174400000X
CAC138034207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5071127OtherCOMM BLUE/BC
NY00010028501OtherUNIVERA
NY0400458OtherIHA
NY00602837Medicaid
NY00010028501OtherUNIVERA
NY00602837Medicaid