Basic Information
| Provider Information | |||||||||
| NPI: | 1558306720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | WILLIS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25370 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968250370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085360300 | ||||||||
| FaxNumber: | 8085360320 | ||||||||
| Practice Location | |||||||||
| Address1: | 91-2139 FORT WEAVER ROAD | ||||||||
| Address2: | #213 | ||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086712456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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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 | 207RI0200X | 6115 | HI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 00661001 | 05 | HI | MEDICAID |