Provider Demographics
NPI:1699925420
Name:CHANG, ELLEN J (OD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:J
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 1:5570 XAVIER DR
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-1322
Mailing Address - Country:US
Mailing Address - Phone:310-923-1712
Mailing Address - Fax:
Practice Address - Street 1:5570 XAVIER DR
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704-1322
Practice Address - Country:US
Practice Address - Phone:914-962-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT13619152W00000X, 152WL0500X
NYTUV007437-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation