=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386662591
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT CHANG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 05/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1299 PORTLAND AVE STE 3
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14621-2727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-922-5520
-----------------------------------------------------
Fax | 585-922-5526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1425 PORTLAND AVE STE 6
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14621-3001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-922-5525
-----------------------------------------------------
Fax | 585-922-5526
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 158925
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------