Healthcare Provider Details

I. General information

NPI: 1265788228
Provider Name (Legal Business Name): JUSTIN CHANG DO, FAAHPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 3RD ST STE 2
EUREKA CA
95501-0460
US

IV. Provider business mailing address

8690 SIERRA COLLEGE BLVD STE 160-306
ROSEVILLE CA
95661-5961
US

V. Phone/Fax

Practice location:
  • Phone: 707-442-5683
  • Fax:
Mailing address:
  • Phone: 822-332-8896
  • Fax: 512-777-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO1879
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS016066
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDO1879
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number20A18091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: