Healthcare Provider Details

I. General information

NPI: 1336176080
Provider Name (Legal Business Name): TIFFANY W. CHANG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 04/05/2011
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 TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4549
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTPL 13471
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: