Provider Demographics
NPI:1376860056
Name:CHANG, ALEXANDER TAE-SHIK (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:TAE-SHIK
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 1:120 CRAVEN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4237
Mailing Address - Country:US
Mailing Address - Phone:760-291-6650
Mailing Address - Fax:760-737-3430
Practice Address - Street 1:2130 CITRACADO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4151
Practice Address - Country:US
Practice Address - Phone:760-739-7666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA123245208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA123245OtherMEDICAL LICENSE