Provider Demographics
NPI:1992718530
Name:CHANG, MIMI A (MD)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:A
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:22 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08812-1830
Mailing Address - Country:US
Mailing Address - Phone:732-868-1038
Mailing Address - Fax:
Practice Address - Street 1:15 JAMES ST STE 2
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1346
Practice Address - Country:US
Practice Address - Phone:973-822-3338
Practice Address - Fax:973-822-8098
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA649732081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G43185Medicare UPIN