Provider Demographics
NPI:1740290857
Name:CHOI, CHANG SONG (MD)
Entity type:Individual
Prefix:MR
First Name:CHANG
Middle Name:SONG
Last Name:CHOI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:P.O. BOX 1239
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06011-1239
Mailing Address - Country:US
Mailing Address - Phone:860-589-6919
Mailing Address - Fax:860-582-2890
Practice Address - Street 1:46 GOODWIN STREET
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:860-589-6919
Practice Address - Fax:860-582-2890
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT015857207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001158575Medicaid
0551710001Medicare NSC
CTD76964Medicare UPIN
CT001158575Medicaid