Basic Information
| Provider Information | |||||||||
| NPI: | 1265488126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | YUNG | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2004 FALLS BLVD | ||||||||
| Address2: | #201 | ||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021698200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417150 | ||||||||
| FaxNumber: | 5089416104 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417150 | ||||||||
| FaxNumber: | 5089416104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 221632 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2067811 | 05 | MA | MEDICAID |