Healthcare Provider Details

I. General information

NPI: 1750410262
Provider Name (Legal Business Name): CATHERINE KYONGA CHANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 ZION AVE
SAN DIEGO CA
92120-2507
US

IV. Provider business mailing address

4647 ZION AVE
SAN DIEGO CA
92120-2507
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-7931
  • Fax: 319-528-3777
Mailing address:
  • Phone: 619-528-7931
  • Fax: 319-528-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA79317
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME107331
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA79317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: