Provider Demographics
NPI:1699052159
Name:CHANG, JOHNNY (DPT, LAC)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DPT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MICHAELS LN
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-2014
Mailing Address - Country:US
Mailing Address - Phone:516-424-3317
Mailing Address - Fax:
Practice Address - Street 1:7412 88TH ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7952
Practice Address - Country:US
Practice Address - Phone:646-493-9386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033956225100000X
NY005315171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist