Provider Demographics
NPI:1205061835
Name:CHANGCHIEN, STEPHANIE JAMIE (MD)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JAMIE
Last Name:CHANGCHIEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:JAMIE
Other - Last Name:YEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M D
Mailing Address - Street 1:770 MAGNOLIA AVE STE 1K
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3122
Mailing Address - Country:US
Mailing Address - Phone:951-738-0303
Mailing Address - Fax:
Practice Address - Street 1:770 MAGNOLIA AVE STE 1K
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3122
Practice Address - Country:US
Practice Address - Phone:951-738-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106116207Q00000X
IL036125294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL728780020OtherMEDICARE PTAN
CAP02038898OtherMEDICARE PTAN