Healthcare Provider Details

I. General information

NPI: 1790888006
Provider Name (Legal Business Name): SIDNEY TAN CHANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR REGENTS OF THE UNIVERSITY OF CALIFORNIA
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

200 W ARBOR DRIVE REGENTS OF THE UNIVERSITY OF CALIFORNIA
SAN DIEGO CA
92103-1350
US

V. Phone/Fax

Practice location:
  • Phone: 858-534-6290
  • Fax:
Mailing address:
  • Phone: 858-534-6290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2008017344
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD-15590
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD74915
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA125489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: