Provider Demographics
NPI:1457344186
Name:CHANG, JUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:STE 206
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-5735
Mailing Address - Country:US
Mailing Address - Phone:770-300-0559
Mailing Address - Fax:770-300-9176
Practice Address - Street 1:4720 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:STE 206
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-5735
Practice Address - Country:US
Practice Address - Phone:770-300-0559
Practice Address - Fax:770-300-9176
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001753152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000980735AMedicaid
GA41ZCDNDMedicare ID - Type Unspecified
GA000980735AMedicaid