Basic Information
| Provider Information | |||||||||
| NPI: | 1720064827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | BONG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020A E BOAL AVE | ||||||||
| Address2: | |||||||||
| City: | BOALSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168271509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142378627 | ||||||||
| FaxNumber: | 8142380083 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 ROUTE 72 W | ||||||||
| Address2: | |||||||||
| City: | MANAHAWKIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080502412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099782194 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | MA04440400 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4319635 | 01 | NJ | AETNA PPO | OTHER | 0128805 | 05 | NJ | MEDICAID | 1K5038 | 01 | NJ | HEALTHNET | OTHER | 2351609 | 01 | NJ | AETNA HMO | OTHER | 0231571000 | 01 | NJ | AMERIHEALTH HMO/POS | OTHER | 28536 | 01 | NJ | UNIVERSITY HEALTH PLAN | OTHER | P2063667 | 01 | NJ | OXFORD | OTHER | 400377 | 01 | NJ | AMERIHEALTH PPO | OTHER |