Provider Demographics
NPI:1639201635
Name:CHANG, CHONG C (MD)
Entity Type:Individual
Prefix:
First Name:CHONG
Middle Name:C
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 1:19875 SW 65TH AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8353
Mailing Address - Country:US
Mailing Address - Phone:503-691-1743
Mailing Address - Fax:503-691-0983
Practice Address - Street 1:19875 SW 65TH AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8353
Practice Address - Country:US
Practice Address - Phone:503-691-1743
Practice Address - Fax:503-691-0983
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13588174400000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR104752Medicaid
ORR108315Medicare PIN
OR104752Medicaid