Provider Demographics
NPI:1669444279
Name:CHANG, KEUCK (MD)
Entity Type:Individual
Prefix:
First Name:KEUCK
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEUCKEE
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6789 RIDGE RD
Mailing Address - Street 2:STE 203
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129
Mailing Address - Country:US
Mailing Address - Phone:440-888-4426
Mailing Address - Fax:440-888-5033
Practice Address - Street 1:6789 RIDGE RD
Practice Address - Street 2:STE 203
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129
Practice Address - Country:US
Practice Address - Phone:440-888-4426
Practice Address - Fax:440-888-5033
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041642207RN0300X
VA0101238001207RN0300X
CAC52033207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0378247Medicaid
OHCH0486922Medicare ID - Type Unspecified
OH0378247Medicaid