Provider Demographics
NPI:1831496538
Name:CHANG, WILLIS L
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:L
Last Name:CHANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 E HERNDON AVE STE 431
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3309
Mailing Address - Country:US
Mailing Address - Phone:559-450-3889
Mailing Address - Fax:559-450-7473
Practice Address - Street 1:1221 E SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3374
Practice Address - Country:US
Practice Address - Phone:559-450-5777
Practice Address - Fax:559-449-2654
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA130760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program