Provider Demographics
NPI:1871607507
Name:CHANG, MARK K (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 JOLIET ST
Mailing Address - Street 2:STE 104
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1996
Mailing Address - Country:US
Mailing Address - Phone:219-836-4955
Mailing Address - Fax:219-865-2377
Practice Address - Street 1:1100 JOLIET ST
Practice Address - Street 2:STE 104
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1996
Practice Address - Country:US
Practice Address - Phone:219-836-4955
Practice Address - Fax:219-865-2377
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200033540A207X00000X
IL036095817207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095817Medicaid
P00419910OtherRAILROAD MEDICARE
IN200868870AMedicaid
IN251090AMedicare PIN
IL5930340001Medicare NSC
ININ2023Medicare Oscar/Certification
ININ2023Medicare PIN
IL036095817Medicaid
IN200868870AMedicaid
IL215218Medicare PIN