Basic Information
| Provider Information | |||||||||
| NPI: | 1053417808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | ELBERT | ||||||||
| MiddleName: | KC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9525 MONTE VISTA AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917632231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096261205 | ||||||||
| FaxNumber: | 9096251977 | ||||||||
| Practice Location | |||||||||
| Address1: | 9525 MONTE VISTA AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917632231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096261205 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | A89864 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 00A898640 | 05 | CA | MEDICAID |