Healthcare Provider Details

I. General information

NPI: 1205128196
Provider Name (Legal Business Name): ENOCH H CHANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 ALVARADO RD STE 200
SAN DIEGO CA
92120-5256
US

IV. Provider business mailing address

6719 ALVARADO RD STE 200
SAN DIEGO CA
92120-5256
US

V. Phone/Fax

Practice location:
  • Phone: 619-229-3932
  • Fax: 619-582-2860
Mailing address:
  • Phone: 619-229-3934
  • Fax: 619-582-2860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberTMP 02914
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA126071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: