Provider Demographics
NPI:1295033892
Name:CHANG, JITSEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JITSEN
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 1:2001 SANTA MONICA BLVD.
Mailing Address - Street 2:SUITE 468W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-255-0990
Mailing Address - Fax:310-255-0996
Practice Address - Street 1:2001 SANTA MONICA BLVD.
Practice Address - Street 2:SUITE 468W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-255-0990
Practice Address - Fax:310-255-0996
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-05
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA A112949207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology