Provider Demographics
NPI:1962407718
Name:CHANG, MARY W (MD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:W
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:DEPARTMENT OF DERMATOLOGY UCONN HEALTH
Mailing Address - Street 2:21 SOUTH RD, 2ND FLOOR
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:860-679-4600
Mailing Address - Fax:860-679-7534
Practice Address - Street 1:UCONN DERMATOLOGY
Practice Address - Street 2:21 SOUTH ROAD, 2ND FLOOR
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:860-679-4600
Practice Address - Fax:860-679-7534
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT42985207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001429853Medicaid
CTD400013482Medicare PIN
CTF46670Medicare UPIN
CT070000491Medicare ID - Type Unspecified