Healthcare Provider Details

I. General information

NPI: 1821242199
Provider Name (Legal Business Name): JOHANNA CHI CHANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 BIRMINGHAM WAY BLDG 28
SAN DIEGO CA
92123-2758
US

IV. Provider business mailing address

3860 CALLE FORTUNADA STE #210
SAN DIEGO CA
92123-4802
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-8082
  • Fax: 858-966-6791
Mailing address:
  • Phone: 858-309-6303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA98479
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License NumberA98479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: