Provider Demographics
NPI:1558306720
Name:CHANG, WILLIS (MD)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:
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:PO BOX 25370
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-0370
Mailing Address - Country:US
Mailing Address - Phone:808-536-0300
Mailing Address - Fax:808-536-0320
Practice Address - Street 1:91-2139 FORT WEAVER ROAD
Practice Address - Street 2:#213
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706
Practice Address - Country:US
Practice Address - Phone:808-671-2456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI6115207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00661001Medicaid
HIH0000BDTPWMedicare PIN
HIE50822Medicare UPIN