Provider Demographics
NPI:1033165816
Name:CHANG, JEFFREY C (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHIL
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:869 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-2207
Practice Address - Country:US
Practice Address - Phone:559-668-0821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36575207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A365750Medicaid
A13304Medicare UPIN
AR00A365750Medicare PIN
CA00A365750Medicaid
CA050090757Medicare PIN
CABP832ZMedicare PIN
CAP01047671Medicare PIN