Provider Demographics
NPI:1609932417
Name:CHANG, BOONCHOO (MD)
Entity Type:Individual
Prefix:DR
First Name:BOONCHOO
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 1:417 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-1906
Mailing Address - Country:US
Mailing Address - Phone:269-782-7150
Mailing Address - Fax:269-782-7020
Practice Address - Street 1:417 W HIGH ST
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-1906
Practice Address - Country:US
Practice Address - Phone:269-782-7150
Practice Address - Fax:269-782-7020
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031400207QA0505X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093701Medicaid
MI0141181Medicare ID - Type Unspecified
MI1093701Medicaid