Basic Information
| Provider Information | |||||||||
| NPI: | 1164816104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | CHRISTINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 N DECATUR RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300335949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047786400 | ||||||||
| FaxNumber: | 6467708409 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 N DECATUR RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047786400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2015 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 80358 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 133273402 | 01 | NY | STUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM | OTHER |