Provider Demographics
NPI:1336375104
Name:AZEFOR, NCHANG MANTOH (MD)
Entity type:Individual
Prefix:
First Name:NCHANG
Middle Name:MANTOH
Last Name:AZEFOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1215
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67905-1215
Mailing Address - Country:US
Mailing Address - Phone:620-629-3338
Mailing Address - Fax:620-629-6684
Practice Address - Street 1:305 W 15TH ST STE 204
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901
Practice Address - Country:US
Practice Address - Phone:620-624-4946
Practice Address - Fax:620-624-2260
Is Sole Proprietor?:No
Enumeration Date:2009-06-06
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0440303208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200741890AMedicaid
KS201174830AMedicaid