Provider Demographics
NPI:1407860885
Name:CHANG, CHRISTINE M (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:CHANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2359 S. AZUSA AVE.
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792
Mailing Address - Country:US
Mailing Address - Phone:626-913-2244
Mailing Address - Fax:626-913-6204
Practice Address - Street 1:2359 S. AZUSA AVE.
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792
Practice Address - Country:US
Practice Address - Phone:626-913-2244
Practice Address - Fax:626-913-6204
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1111OT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD011110TMedicaid
CASD011110TMedicaid
CAW16043Medicare ID - Type Unspecified