Provider Demographics
NPI:1407922768
Name:CHANG, PHYLLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 5TH ST
Mailing Address - Street 2:PO BOX 5036
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2304
Mailing Address - Country:US
Mailing Address - Phone:319-358-8788
Mailing Address - Fax:319-351-9278
Practice Address - Street 1:604 5TH ST
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2304
Practice Address - Country:US
Practice Address - Phone:319-358-8788
Practice Address - Fax:319-351-9278
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA269972082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1273599Medicaid
IAE07320Medicare UPIN