Provider Demographics
NPI:1679874309
Name:SEUNGKOOK CHANG MD INC
Entity Type:Organization
Organization Name:SEUNGKOOK CHANG MD INC
Other - Org Name:WALNUT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEUNG
Authorized Official - Middle Name:KOOK
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-598-5228
Mailing Address - Street 1:19687 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2146
Mailing Address - Country:US
Mailing Address - Phone:909-598-5228
Mailing Address - Fax:909-598-9021
Practice Address - Street 1:19687 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2146
Practice Address - Country:US
Practice Address - Phone:909-598-5228
Practice Address - Fax:909-598-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35067261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27674Medicare UPIN