Provider Demographics
NPI:1861561219
Name:CHANG, TERRANCE T
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:T
Last Name:CHANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 DOUGLAS BLVD
Mailing Address - Street 2:# 112
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-5936
Mailing Address - Country:US
Mailing Address - Phone:916-791-0797
Mailing Address - Fax:916-791-1479
Practice Address - Street 1:8723 SIERRA COLLEGE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-5920
Practice Address - Country:US
Practice Address - Phone:916-791-0797
Practice Address - Fax:916-791-1479
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33580207K00000X, 207KA0200X, 207KI0005X, 208000000X, 2080I0007X, 2080P0006X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080I0007XAllopathic & Osteopathic PhysiciansPediatricsClinical & Laboratory Immunology
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45600Medicare UPIN
CA00G335800Medicare ID - Type UnspecifiedMEDICARE NUMBER