Provider Demographics
NPI:1356564934
Name:CHANG, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 BROADHOLLOW RD
Mailing Address - Street 2:SUITE 142
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3672
Mailing Address - Country:US
Mailing Address - Phone:516-931-0041
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PARK DR.
Practice Address - Street 2:
Practice Address - City:WEST NYAC
Practice Address - State:NY
Practice Address - Zip Code:10994
Practice Address - Country:US
Practice Address - Phone:845-354-5000
Practice Address - Fax:845-354-9469
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240243-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02889150Medicaid
NYMC005S3071OtherBLUE CROSS
NYW06231Medicare UPIN
NY0527170004Medicare NSC
NY02889150Medicaid