Provider Demographics
NPI:1265642821
Name:WU, CHANGCHUN C (MD)
Entity type:Individual
Prefix:
First Name:CHANGCHUN
Middle Name:C
Last Name:WU
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 1:4319 LAWRENCEVILLE HWY NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3416
Mailing Address - Country:US
Mailing Address - Phone:678-583-8888
Mailing Address - Fax:678-894-4267
Practice Address - Street 1:4319 LAWRENCEVILLE HWY NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3416
Practice Address - Country:US
Practice Address - Phone:678-583-8888
Practice Address - Fax:678-894-4267
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA170144592CMedicaid
GA170144592AMedicaid
GA170144592BMedicaid