Healthcare Provider Details

I. General information

NPI: 1235889585
Provider Name (Legal Business Name): EDWARD JINSOO CHANG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

1334 9TH ST APT 5
SANTA MONICA CA
90401-1829
US

V. Phone/Fax

Practice location:
  • Phone: 310-720-3108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number20A21784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: