Provider Demographics
NPI:1760406789
Name:CHANG, KEVIN W (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
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 28949
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8949
Mailing Address - Country:US
Mailing Address - Phone:559-228-4200
Mailing Address - Fax:559-224-3920
Practice Address - Street 1:7085 N WHITNEY AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8002
Practice Address - Country:US
Practice Address - Phone:559-437-7338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90847208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA90847OtherLICENSE
CA00A908470Medicaid
CA00A908470Medicare PIN
CAI72666Medicare UPIN