Provider Demographics
NPI:1255669057
Name:WILLIAM CHANG OD, INC
Entity Type:Organization
Organization Name:WILLIAM CHANG OD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-291-2020
Mailing Address - Street 1:417 S SAN GABRIEL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1967
Mailing Address - Country:US
Mailing Address - Phone:626-291-2020
Mailing Address - Fax:626-585-2905
Practice Address - Street 1:417 S SAN GABRIEL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1967
Practice Address - Country:US
Practice Address - Phone:626-291-2020
Practice Address - Fax:626-585-2905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACR713ZOtherMEDICARE PTAN
CA1255669057Medicaid
CACR713ZOtherMEDICARE PTAN