Provider Demographics
NPI:1003884164
Name:CHANG, JEANETTE K (MD)
Entity type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:K
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 MONTVALE AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3623
Mailing Address - Country:US
Mailing Address - Phone:781-279-1123
Mailing Address - Fax:781-438-3034
Practice Address - Street 1:91 MONTVALE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3623
Practice Address - Country:US
Practice Address - Phone:781-279-1123
Practice Address - Fax:781-438-3034
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205830208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0195791Medicaid
MAJ24951OtherBCBS
MA0195791Medicaid
MAJ24951OtherBCBS