Healthcare Provider Details

I. General information

NPI: 1982912366
Provider Name (Legal Business Name): JESSE CHANG, M.D. A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 KATELLA AVE #223
LOS ALAMITOS CA
90720-3338
US

IV. Provider business mailing address

713 SOUTHSHORE DR
SEAL BEACH CA
90740-5863
US

V. Phone/Fax

Practice location:
  • Phone: 562-626-8016
  • Fax:
Mailing address:
  • Phone: 562-343-0704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA77482
License Number StateCA

VIII. Authorized Official

Name: DR. JESSE CHANG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 562-343-0704