Provider Demographics
NPI:1922005016
Name:CHANG, CARLOS F (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:F
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 1363
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32756-1363
Mailing Address - Country:US
Mailing Address - Phone:352-343-0053
Mailing Address - Fax:352-343-0059
Practice Address - Street 1:1862 MAYO DRIVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-343-0053
Practice Address - Fax:352-343-0059
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251269602Medicaid
G16153Medicare UPIN
FL251269602Medicaid