Healthcare Provider Details

I. General information

NPI: 1558306720
Provider Name (Legal Business Name): WILLIS CHANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-2139 FORT WEAVER ROAD #213
EWA BEACH HI
96706
US

IV. Provider business mailing address

PO BOX 25370
HONOLULU HI
96825-0370
US

V. Phone/Fax

Practice location:
  • Phone: 808-671-2456
  • Fax:
Mailing address:
  • Phone: 808-536-0300
  • Fax: 808-536-0320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number6115
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: