Provider Demographics
NPI:1437817590
Name:CHANG, SUSAN L (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:L
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 1:8919 SHADY GROVE CT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1308
Mailing Address - Country:US
Mailing Address - Phone:240-644-2303
Mailing Address - Fax:
Practice Address - Street 1:8919 SHADY GROVE CT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1308
Practice Address - Country:US
Practice Address - Phone:240-644-2303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD7CQ5-RC1-TX59170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC-520-778-522-108Medicaid
MDC520778522108Medicaid