Provider Demographics
NPI:1518940162
Name:CHANG, KUO C (MD)
Entity Type:Individual
Prefix:DR
First Name:KUO
Middle Name:C
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 1:9735 SW SHADY LN
Mailing Address - Street 2:#102
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5481
Mailing Address - Country:US
Mailing Address - Phone:503-620-5614
Mailing Address - Fax:503-598-4688
Practice Address - Street 1:9735 SW SHADY LN
Practice Address - Street 2:#102
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5481
Practice Address - Country:US
Practice Address - Phone:503-620-5614
Practice Address - Fax:503-598-4688
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10546174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR243550Medicaid
ORC94241Medicare UPIN
ORR117290Medicare PIN
ORR117292Medicare PIN