Provider Demographics
NPI:1265793277
Name:CHANG, VISHALA (DO)
Entity type:Individual
Prefix:MRS
First Name:VISHALA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16960
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-6960
Mailing Address - Country:US
Mailing Address - Phone:305-243-6837
Mailing Address - Fax:305-243-8470
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-243-6837
Practice Address - Fax:305-243-8470
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO3220390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program