Basic Information
| Provider Information | |||||||||
| NPI: | 1598930398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | KYUNG HEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | RAYNHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027671942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5085650012 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | RAYNHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027671942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5085650012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2008 | ||||||||
| LastUpdateDate: | 05/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 237853 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 12908 | RI | N | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | KC75976 | 05 | RI | MEDICAID |