Provider Demographics
NPI:1295795078
Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Entity type:Organization
Organization Name:COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-393-8582
Mailing Address - Street 1:1701 HIGH STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704
Mailing Address - Country:US
Mailing Address - Phone:757-393-8585
Mailing Address - Fax:757-393-8027
Practice Address - Street 1:1701 HIGH STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704
Practice Address - Country:US
Practice Address - Phone:757-393-8585
Practice Address - Fax:757-393-8027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-7512-0Medicaid
600699130Medicare PIN