Provider Demographics
NPI:1619975182
Name:CHANG, JOHNNY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:A
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 1:538 LITCHFIELD ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6669
Mailing Address - Country:US
Mailing Address - Phone:860-496-8990
Mailing Address - Fax:860-496-7301
Practice Address - Street 1:538 LITCHFIELD ST
Practice Address - Street 2:SUITE 102
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6669
Practice Address - Country:US
Practice Address - Phone:860-496-8990
Practice Address - Fax:860-496-7301
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041177174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0000231610801OtherUNITED HEALTHCARE ID
CT1411777Medicaid
CT3159551OtherAETNA PROVIDER ID
CT041177OtherCONNECTICARE PROVIDER ID
CT2V4421OtherHEALTHNET PROVIDER ID
CT00141177700OtherBLUE CARE FAMILY PLAN ID
CT010041177CT01OtherBLUE SHIELD PROVIDER ID
CTP2882366OtherOXFORD PROVIDER ID
CT3159551OtherAETNA PROVIDER ID