Provider Demographics
NPI:1467157305
Name:CHANG, DEREK KONG-JYUE (MD, MSPH)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:KONG-JYUE
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD, MSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MARIO CAPECCHI DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-8509
Mailing Address - Country:US
Mailing Address - Phone:801-581-7899
Mailing Address - Fax:
Practice Address - Street 1:30 NORTH MARIO CAPECCHI DRIVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-8509
Practice Address - Country:US
Practice Address - Phone:801-581-7899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR80180207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine