Provider Demographics
NPI:1669451738
Name:CHANG, KEON (MD)
Entity Type:Individual
Prefix:
First Name:KEON
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 1:5623 E DUNBAR RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-9127
Mailing Address - Country:US
Mailing Address - Phone:734-241-3891
Mailing Address - Fax:734-241-0014
Practice Address - Street 1:2001 S MERRIMAN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5544
Practice Address - Country:US
Practice Address - Phone:734-729-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037628174400000X
MI0376282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2884620 10Medicaid
MI2884620 10Medicaid
MI0825782Medicare PIN
MI0N15280003Medicare PIN