1285632463 NPI number — JIMMY C CHANG MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285632463 NPI number — JIMMY C CHANG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANG
Provider First Name:
JIMMY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285632463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3343 SPRINGHILL DR
Provider Second Line Business Mailing Address:
STE 1005
Provider Business Mailing Address City Name:
NORTH LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72117-2930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-758-9251
Provider Business Mailing Address Fax Number:
501-758-0308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3343 SPRINGHILL DR
Provider Second Line Business Practice Location Address:
STE 1005
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72117-2930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-758-9251
Provider Business Practice Location Address Fax Number:
501-758-0308
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  C5948 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11257000000 . This is a "QUALCHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 160021272 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 111261001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 242061 . This is a "HEALTHLINK" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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