Basic Information
| Provider Information | |||||||||
| NPI: | 1285053686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127215 | ||||||||
| FaxNumber: | 5018127215 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 SPRINGHILL DR # 130 | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721172910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019552741 | ||||||||
| FaxNumber: | 5019554558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | E11203 | AR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | E11203 | 01 | AR | ARKANSAS STATE MEDICAL BOARD | OTHER |