Provider Demographics
NPI:1770504649
Name:JIN, CHANG KON (MD)
Entity Type:Individual
Prefix:
First Name:CHANG KON
Middle Name:
Last Name:JIN
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 2127
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36202-2127
Mailing Address - Country:US
Mailing Address - Phone:256-236-5631
Mailing Address - Fax:256-236-5637
Practice Address - Street 1:1010 CHRISTINE AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-5710
Practice Address - Country:US
Practice Address - Phone:256-236-5631
Practice Address - Fax:256-236-5637
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00006505207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL3610078OtherUNITED HEALTHCARE
AL01191Medicare PIN
ALD08170Medicare UPIN
AL3610078OtherUNITED HEALTHCARE