Healthcare Provider Details

I. General information

NPI: 1093005050
Provider Name (Legal Business Name): TIFFANY W. CHANG, OD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10430 S DE ANZA BLVD SUITE 100
CUPERTINO CA
95014-3098
US

IV. Provider business mailing address

10430 S DE ANZA BLVD SUITE 100
CUPERTINO CA
95014-3098
US

V. Phone/Fax

Practice location:
  • Phone: 408-865-0440
  • Fax: 408-865-0411
Mailing address:
  • Phone: 408-865-0440
  • Fax: 408-865-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTPL 13471
License Number StateCA

VIII. Authorized Official

Name: DR. TIFFANY WEI CHANG
Title or Position: PRESIDENT
Credential: OD
Phone: 781-354-8937