Provider Demographics
NPI:1952357253
Name:CHANG, BERNARD W (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:W
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:PO BOX 64075
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 SAINT PAUL PL
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2001
Practice Address - Country:US
Practice Address - Phone:410-332-9700
Practice Address - Fax:410-545-4330
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0038983208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD182171700Medicaid
MDS186 / 0004OtherBLUECHOICE
MDKG65 / 525674-06OtherBC / BS OF MD
MDS186 / 0004OtherBLUECHOICE
MDKG65 / 525674-06OtherBC / BS OF MD