Provider Demographics
NPI:1043713258
Name:CHANG, SUE
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 FORT SUMTER
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-2530
Mailing Address - Country:US
Mailing Address - Phone:714-746-6724
Mailing Address - Fax:
Practice Address - Street 1:1835 NEWPORT BLVD # C
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-5031
Practice Address - Country:US
Practice Address - Phone:949-722-1750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN9092477OtherDRIVERS LICENSE