Provider Demographics
NPI:1811182041
Name:CHANG, JACK C (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:C
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:706 ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-4338
Mailing Address - Country:US
Mailing Address - Phone:978-937-9333
Mailing Address - Fax:978-937-9992
Practice Address - Street 1:706 ROGERS ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-4338
Practice Address - Country:US
Practice Address - Phone:978-937-9333
Practice Address - Fax:978-937-9992
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ13158OtherBLUE CROSS BLUE SHIELD
MA074694OtherTUFTS
MA3103391Medicaid
MAJ13158Medicare PIN
MA074694OtherTUFTS