Provider Demographics
NPI:1831195882
Name:CHANG, RICHARD C (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
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 1:16465 SIERRA LAKES PKWY STE 245
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336
Mailing Address - Country:US
Mailing Address - Phone:909-829-7337
Mailing Address - Fax:909-829-1218
Practice Address - Street 1:16465 SIERRA PARKWAY
Practice Address - Street 2:# 245
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92236
Practice Address - Country:US
Practice Address - Phone:909-829-7337
Practice Address - Fax:909-829-1218
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86339208000000X
TXL0074208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX760530251OtherTAX ID
TX8G2996OtherBLUE CROSS & BLUE SHIELD
TX160280701Medicaid
CAA86339OtherCALIFORNIA MEDICAL LICENSE
TXL0074OtherMEDICAL LICENSE
TX760530251OtherTAX ID
TX8A7519Medicare ID - Type Unspecified