Provider Demographics
NPI:1508868787
Name:JOO, CHANG S (MD)
Entity Type:Individual
Prefix:
First Name:CHANG
Middle Name:S
Last Name:JOO
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 1:305 E GRANGER AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4344
Mailing Address - Country:US
Mailing Address - Phone:209-526-1606
Mailing Address - Fax:209-526-1677
Practice Address - Street 1:305 E GRANGER AVE
Practice Address - Street 2:STE 202
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4344
Practice Address - Country:US
Practice Address - Phone:209-526-1606
Practice Address - Fax:209-526-1677
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA481920207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A481920Medicaid
CA00A481920Medicaid
CAF86579Medicare UPIN