Provider Demographics
NPI:1427212497
Name:CHANG, TINA TING-LI (OD, MS)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:TING-LI
Last Name:CHANG
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 BOAR CIR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-6042
Mailing Address - Country:US
Mailing Address - Phone:510-579-6365
Mailing Address - Fax:
Practice Address - Street 1:596 BOAR CIR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-6042
Practice Address - Country:US
Practice Address - Phone:510-579-6365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007274152W00000X
CAOPT 13689 TPA152WL0500X
AZ1645152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP982AOtherCERTIFICATE OF SPECIAL QUALIFICATION