Provider Demographics
NPI:1609371970
Name:CHANG, KENNETH GALEN (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GALEN
Last Name:CHANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PARNASSUS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2204
Mailing Address - Country:US
Mailing Address - Phone:352-265-0239
Mailing Address - Fax:352-265-1107
Practice Address - Street 1:1600 SW ARCHER RD STE 4102
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-9239
Practice Address - Fax:352-265-1197
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A18780208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program