Provider Demographics
NPI:1750473344
Name:CHANG, LAWRENCE W (OD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:W
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:PO BOX 3622
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91031-6622
Mailing Address - Country:US
Mailing Address - Phone:626-799-6968
Mailing Address - Fax:
Practice Address - Street 1:477 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101
Practice Address - Country:US
Practice Address - Phone:626-796-1191
Practice Address - Fax:626-796-0189
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8207T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0082070Medicaid
CASD0082070Medicaid
CAWOP8207AMedicare PIN