Healthcare Provider Details

I. General information

NPI: 1639201635
Provider Name (Legal Business Name): CHONG C CHANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19875 SW 65TH AVE SUITE 260
TUALATIN OR
97062-8353
US

IV. Provider business mailing address

19875 SW 65TH AVE SUITE 260
TUALATIN OR
97062-8353
US

V. Phone/Fax

Practice location:
  • Phone: 503-691-1743
  • Fax: 503-691-0983
Mailing address:
  • Phone: 503-691-1743
  • Fax: 503-691-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD13588
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD13588
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: