Provider Demographics
NPI:1740316041
Name:CHANG, CHI (OD)
Entity type:Individual
Prefix:DR
First Name:CHI
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 S VARNA ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6128
Mailing Address - Country:US
Mailing Address - Phone:206-769-1918
Mailing Address - Fax:909-646-7097
Practice Address - Street 1:3333 BRISTOL ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1873
Practice Address - Country:US
Practice Address - Phone:714-754-1869
Practice Address - Fax:714-754-1871
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41376152W00000X
WA3812152W00000X
CA14376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2028223Medicaid