Provider Demographics
NPI:1588673644
Name:CHANG, VANESSA Q (MD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:Q
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:#307
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8323
Practice Address - Country:US
Practice Address - Phone:262-948-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1107332084P0800X
WI477392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34644100Medicaid