Provider Demographics
NPI:1962485037
Name:CHANG, DONGWOO JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DONGWOO
Middle Name:JOHN
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DONGWOO
Other - Middle Name:JOHN
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-351-4972
Mailing Address - Fax:618-351-4973
Practice Address - Street 1:305 W JACKSON ST STE 400
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-351-4972
Practice Address - Fax:618-351-4973
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120333207T00000X, 207T00000X
NY296766207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK52478Medicare PIN
H09329Medicare UPIN