Provider Demographics
NPI:1629074810
Name:CHANG, HARVEY CHUNG-DER (MD)
Entity Type:Individual
Prefix:
First Name:HARVEY
Middle Name:CHUNG-DER
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 1:2625 COFFEE RD
Mailing Address - Street 2:STE S
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2050
Mailing Address - Country:US
Mailing Address - Phone:209-577-1200
Mailing Address - Fax:209-577-6517
Practice Address - Street 1:4301 N STAR WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9262
Practice Address - Country:US
Practice Address - Phone:209-577-1200
Practice Address - Fax:209-577-6517
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50076207ZP0102X, 207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA51897OtherLICENSE
CAC50076OtherLICENSE
CAP00037347OtherRAILROAD
CAP00037347OtherRAILROAD
CAG62909Medicare UPIN