Provider Demographics
NPI:1770502296
Name:CHANG, MATTY (OD)
Entity Type:Individual
Prefix:
First Name:MATTY
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N TUSTIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-7776
Mailing Address - Country:US
Mailing Address - Phone:714-997-7500
Mailing Address - Fax:714-997-4864
Practice Address - Street 1:311 N TUSTIN ST STE B
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7776
Practice Address - Country:US
Practice Address - Phone:714-997-7500
Practice Address - Fax:714-997-4864
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12280T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV03856Medicare UPIN