Provider Demographics
NPI:1275593261
Name:CHANG, LYNDON (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNDON
Middle Name:
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 1:4910 DIRECTORS PL STE 150
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3801
Mailing Address - Country:US
Mailing Address - Phone:855-360-6730
Mailing Address - Fax:
Practice Address - Street 1:4910 DIRECTORS PL STE 150
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3801
Practice Address - Country:US
Practice Address - Phone:855-360-6730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192851174400000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG89081OtherSTATE LICENSE
NYP2526820OtherOXFORD ID #
NY0297816OtherGHI PPO ID #
NY7672216OtherAETNA PPO ID #
NY000000073002OtherGHI HMO ID #
NY2631049OtherAETNA HMO ID #
NY192851OtherHIP ID #
NYN97319OtherHEALTHNET #
NY01586814Medicaid
NY475C41OtherEMPIRE BC/BS OF NY ID #
NYN97319OtherHEALTHNET #
NY01586814Medicaid