Provider Demographics
NPI:1891182374
Name:CHANG, IVY (MD)
Entity Type:Individual
Prefix:
First Name:IVY
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 1:898 N PACIFIC COAST HWY STE 600
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2747
Mailing Address - Country:US
Mailing Address - Phone:310-698-5452
Mailing Address - Fax:
Practice Address - Street 1:1145 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3511
Practice Address - Country:US
Practice Address - Phone:310-538-6629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA160546207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty