Healthcare Provider Details

I. General information

NPI: 1801246798
Provider Name (Legal Business Name): JAEWON CHANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HOFFMAN ST
ELMIRA NY
14905-2263
US

IV. Provider business mailing address

571 SAINT JOSEPHS BLVD FL 2
ELMIRA NY
14901-3230
US

V. Phone/Fax

Practice location:
  • Phone: 607-734-4110
  • Fax:
Mailing address:
  • Phone: 607-271-2050
  • Fax: 607-873-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number317210
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOT017024
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: