Provider Demographics
NPI:1538367321
Name:CHANG, SU CHOO (MD)
Entity type:Individual
Prefix:DR
First Name:SU CHOO
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-657-6592
Mailing Address - Fax:
Practice Address - Street 1:1627 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3817
Practice Address - Country:US
Practice Address - Phone:574-262-0313
Practice Address - Fax:574-389-4879
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067482A208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200999490Medicaid