Healthcare Provider Details

I. General information

NPI: 1457358897
Provider Name (Legal Business Name): PEN-LAING CHANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6339 DAYLILY CT
RANCHO CUCAMONGA CA
91737-3658
US

IV. Provider business mailing address

6339 DAYLILY CT
RANCHO CUCAMONGA CA
91737-3658
US

V. Phone/Fax

Practice location:
  • Phone: 909-989-3875
  • Fax:
Mailing address:
  • Phone: 909-989-3875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA44876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: