Basic Information
| Provider Information | |||||||||
| NPI: | 1881181717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 E ARIZONA AVE | ||||||||
| Address2: | |||||||||
| City: | SWEETWATER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795567119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252358641 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 E ARIZONA AVE | ||||||||
| Address2: | |||||||||
| City: | SWEETWATER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795567119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252358641 | ||||||||
| FaxNumber: | 3252358708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | S9119 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.