Basic Information
| Provider Information | |||||||||
| NPI: | 1962407718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPARTMENT OF DERMATOLOGY UCONN HEALTH | ||||||||
| Address2: | 21 SOUTH RD, 2ND FLOOR | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794600 | ||||||||
| FaxNumber: | 8606797534 | ||||||||
| Practice Location | |||||||||
| Address1: | UCONN DERMATOLOGY | ||||||||
| Address2: | 21 SOUTH ROAD, 2ND FLOOR | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794600 | ||||||||
| FaxNumber: | 8606797534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NP0225X | 42985 | CT | Y | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 001429853 | 05 | CT | MEDICAID |