Provider Demographics
NPI:1457673733
Name:CHANG, DONG SOO
Entity Type:Individual
Prefix:DR
First Name:DONG SOO
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-1902
Mailing Address - Country:US
Mailing Address - Phone:718-433-0042
Mailing Address - Fax:718-476-1857
Practice Address - Street 1:4520 43RD AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-1902
Practice Address - Country:US
Practice Address - Phone:718-433-0042
Practice Address - Fax:718-476-1857
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-27
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003408171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist