Provider Demographics
NPI:1720378151
Name:CHANG, SHELLEY (MD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
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 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-2582
Mailing Address - Fax:
Practice Address - Street 1:1441 EASTLAKE AVENUE NTT 2424
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-5313
Practice Address - Country:US
Practice Address - Phone:323-442-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA126072207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program