Provider Demographics
NPI:1881181717
Name:CHANG, KENNETH G (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:CHANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-4709
Mailing Address - Country:US
Mailing Address - Phone:626-281-3383
Mailing Address - Fax:855-710-5853
Practice Address - Street 1:1000 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-4709
Practice Address - Country:US
Practice Address - Phone:626-281-3383
Practice Address - Fax:855-710-5853
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19070207Q00000X
TXS9119207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program