Provider Demographics
NPI:1629206834
Name:CHANG, WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 S SAN GABRIEL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1967
Mailing Address - Country:US
Mailing Address - Phone:626-291-2020
Mailing Address - Fax:626-585-2905
Practice Address - Street 1:417 S SAN GABRIEL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1967
Practice Address - Country:US
Practice Address - Phone:626-291-2020
Practice Address - Fax:626-585-2905
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATLG13713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACR713ZOtherMEDICARE PTAN