Provider Demographics
NPI:1245364926
Name:CHANG, BRIAN K (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
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 1:7910 W JEFFERSON BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-436-4116
Mailing Address - Fax:260-459-2504
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-9100
Practice Address - Fax:260-266-9110
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063272A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245364926Medicaid
IN200857850Medicaid
OH2735259Medicaid
OH2735259Medicaid
MI1245364926Medicaid
INP00431695Medicare PIN
INP00431695Medicare PIN
IN000000614687OtherANTHEM PIN
IN200857850Medicaid
MI104994908Medicaid