Healthcare Provider Details

I. General information

NPI: 1619471893
Provider Name (Legal Business Name): LAWRENCE CHANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 09/25/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 16TH ST BOX 0649
SAN FRANCISCO CA
94158-2545
US

IV. Provider business mailing address

550 16TH ST
SAN FRANCISCO CA
94143-2549
US

V. Phone/Fax

Practice location:
  • Phone: 415-613-3901
  • Fax:
Mailing address:
  • Phone: 415-353-1238
  • Fax: 415-353-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number287301
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA196458
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberA196458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: