Provider Demographics
NPI:1841729910
Name:CHANG, JUSTIN THEODORE (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THEODORE
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 LOGAN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1916
Mailing Address - Country:US
Mailing Address - Phone:319-235-3838
Mailing Address - Fax:
Practice Address - Street 1:1825 LOGAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA47374207Q00000X
MO2017018876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine