Provider Demographics
NPI:1629082300
Name:CHANG, JIMMY (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
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 1:657 WILLOW GROVE ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-1868
Mailing Address - Country:US
Mailing Address - Phone:908-850-7800
Mailing Address - Fax:908-850-7802
Practice Address - Street 1:657 WILLOW GROVE ST
Practice Address - Street 2:SUITE 401
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-1868
Practice Address - Country:US
Practice Address - Phone:908-850-7800
Practice Address - Fax:908-850-7802
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06550000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG37470Medicare UPIN