MEDICARE: GWENDOLEN CHANG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A106132	CA

General Provider Information

NPI Number	:	1386807402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLEN CHANG M.D.

Provider Business Mailing Address
First Line	:	13851 E 14TH ST STE 206
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94578-2627
Country	:	US
Telephone Number	:	510-351-9373
Fax Number	:	510-351-0616

Provider Business Practice Location Address
First Line	:	13851 E 14TH ST STE 206
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94578-2627
Country	:	US
Telephone Number	:	510-351-9373
Fax Number	:	510-351-0616

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	12/04/2013

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