Healthcare Provider Details

I. General information

NPI: 1598795221
Provider Name (Legal Business Name): CARLOS CHANG MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 SALK AVE
TAVARES FL
32778
US

IV. Provider business mailing address

PO BOX 1363
MT DORA FL
32756
US

V. Phone/Fax

Practice location:
  • Phone: 352-343-0053
  • Fax: 352-343-0059
Mailing address:
  • Phone: 352-343-0053
  • Fax: 352-343-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME71903
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME71903
License Number StateFL

VIII. Authorized Official

Name: CARLOS CHANG
Title or Position: OWNER
Credential: MD
Phone: 352-343-0053