Provider Demographics
NPI:1952308041
Name:CHANG, GARRICK CHI-REY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARRICK
Middle Name:CHI-REY
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2801 K ST STE 502
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5119
Practice Address - Country:US
Practice Address - Phone:916-646-8300
Practice Address - Fax:916-920-4434
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG666442085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F67313Medicare UPIN
CACA114203Medicare PIN
CA00G666440Medicare ID - Type Unspecified