Provider Demographics
NPI:1770675928
Name:CHANG, WILBUR (MD-PHD)
Entity Type:Individual
Prefix:DR
First Name:WILBUR
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD-PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:301-929-7597
Practice Address - Street 1:10810 CONNECTICUT AVE
Practice Address - Street 2:RADIOLOGY
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2138
Practice Address - Country:US
Practice Address - Phone:301-929-7100
Practice Address - Fax:301-929-7597
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063067207X00000X, 2085R0202X
DCMD0389732085R0202X
VA01012482642085R0202X
GA882472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD417262100Medicaid
P00751352OtherRR MEDICARE PTAN - AAD
MD154636ZDYCOtherRR MEDICARE ARA PTAN
MD1073OtherAAD BLUE CHOICE
MD1073OtherAAD BCBS REGIONAL PLANS
MDS645OtherAAD BCBS