Provider Demographics
NPI:1659364412
Name:CHANG, CHARLES S (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
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:PO BOX 262449
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75026-2449
Mailing Address - Country:US
Mailing Address - Phone:214-778-2530
Mailing Address - Fax:214-778-2542
Practice Address - Street 1:4001 W 15TH ST
Practice Address - Street 2:SUITE 260
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5841
Practice Address - Country:US
Practice Address - Phone:214-778-2530
Practice Address - Fax:214-778-2542
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206001207T00000X
NH11048207T00000X
TXH3003207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1023240751OtherGROUP NPI
TX130364608Medicaid
TXH3003OtherTX LICENSE #
TX8CC790OtherBLUE CROSS PROVIDER NUMBER
TXH3003OtherTX LICENSE #