Basic Information
| Provider Information | |||||||||
| NPI: | 1831175942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | BASIL | ||||||||
| MiddleName: | TZU LI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4800 WESTLAKE PKWY | ||||||||
| Address2: | UNIT# 2804 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958352071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103481917 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4150 V ST | ||||||||
| Address2: | STE 3400 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167347506 | ||||||||
| FaxNumber: | 9167347924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 1249 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 34.012490 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 1249 | NV | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 12686 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | O-0638 | ID | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 12686 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100507010 | 05 | NV | MEDICAID |