Provider Demographics
NPI:1386796480
Name:CHANG, PATRICIA (OD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-2509
Mailing Address - Country:US
Mailing Address - Phone:650-697-2475
Mailing Address - Fax:650-692-7154
Practice Address - Street 1:305 BROADWAY
Practice Address - Street 2:
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-2509
Practice Address - Country:US
Practice Address - Phone:650-697-2475
Practice Address - Fax:650-692-7154
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6412T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10314Medicare UPIN
CASD0064121Medicare ID - Type Unspecified