Provider Demographics
NPI:1558400663
Name:CHANG, JASON (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3907
Mailing Address - Country:US
Mailing Address - Phone:805-542-0700
Mailing Address - Fax:805-784-9309
Practice Address - Street 1:1414 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4806
Practice Address - Country:US
Practice Address - Phone:805-925-2637
Practice Address - Fax:805-347-0033
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13148T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABG230YMedicare Oscar/Certification
CABG230WMedicare PIN