Healthcare Provider Details

I. General information

NPI: 1427131150
Provider Name (Legal Business Name): BONG S CHANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3671 W 6TH ST
LOS ANGELES CA
90020-3026
US

IV. Provider business mailing address

3671 W 6TH ST
LOS ANGELES CA
90020
US

V. Phone/Fax

Practice location:
  • Phone: 213-383-8496
  • Fax: 213-365-9155
Mailing address:
  • Phone: 213-383-8496
  • Fax: 213-365-9133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA341580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: