Provider Demographics
NPI:1689611337
Name:CHANG, KU-JUEY RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:KU-JUEY RAYMOND
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 511345
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7900
Mailing Address - Country:US
Mailing Address - Phone:916-949-9100
Mailing Address - Fax:
Practice Address - Street 1:23331 EL TORO RD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4891
Practice Address - Country:US
Practice Address - Phone:949-916-9100
Practice Address - Fax:949-916-0091
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG181497207RN0300X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG96956Medicare UPIN
CAWG81497CMedicare PIN