Healthcare Provider Details

I. General information

NPI: 1619975182
Provider Name (Legal Business Name): JOHNNY A. CHANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 SAYBROOK RD
MIDDLETOWN CT
06457-4777
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3650
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-2270
  • Fax: 860-358-2275
Mailing address:
  • Phone: 860-358-6000
  • Fax: 860-358-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number041177
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number041177
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: