Provider Demographics
NPI:1457358897
Name:CHANG, PEN-LAING (MD)
Entity type:Individual
Prefix:
First Name:PEN-LAING
Middle Name:
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 1:6339 DAYLILY CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-3658
Mailing Address - Country:US
Mailing Address - Phone:909-989-3875
Mailing Address - Fax:
Practice Address - Street 1:6339 DAYLILY CT
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91737-3658
Practice Address - Country:US
Practice Address - Phone:909-989-3875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA448762080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44876Medicaid
NJ3966909Medicaid
NJ863354Medicare ID - Type Unspecified
CAA44876Medicaid