Provider Demographics
NPI:1598795221
Name:CARLOS CHANG MD PA
Entity type:Organization
Organization Name:CARLOS CHANG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-343-0053
Mailing Address - Street 1:PO BOX 1363
Mailing Address - Street 2:
Mailing Address - City:MT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32756
Mailing Address - Country:US
Mailing Address - Phone:352-343-0053
Mailing Address - Fax:352-343-0059
Practice Address - Street 1:1932 SALK AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-343-0053
Practice Address - Fax:352-343-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71903207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251269602Medicaid
FLK6410Medicare ID - Type UnspecifiedGROUP
FLDC6055 RAILROADMedicare PIN