Provider Demographics
NPI:1780637199
Name:CHANG, EDWARD T (MD)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:T
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3445 TIZIANO CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-2737
Mailing Address - Country:US
Mailing Address - Phone:626-318-5099
Mailing Address - Fax:800-960-7130
Practice Address - Street 1:111 N ATLANTIC BLVD STE 242
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1578
Practice Address - Country:US
Practice Address - Phone:626-318-5099
Practice Address - Fax:800-960-7130
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA755780207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A755780Medicaid
CAH65514Medicare UPIN
CA00A755780Medicare PIN
CA00A755780Medicaid