Provider Demographics
NPI:1659448694
Name:CHANG, ANDY (MPT)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 VILLA LA JOLLA DR
Mailing Address - Street 2:STE A125
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-452-3502
Mailing Address - Fax:858-452-3503
Practice Address - Street 1:8950 VILLA LA JOLLA DR
Practice Address - Street 2:STE A125
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-452-3502
Practice Address - Fax:858-452-3503
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 30242225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist