Basic Information
Provider Information | |||||||||
NPI: | 1922291020 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHANG | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1650 RESPONSE RD | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958154807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164715035 | ||||||||
FaxNumber: | 8777384262 | ||||||||
Practice Location | |||||||||
Address1: | 8170 LAGUNA BLVD | ||||||||
Address2: | #215 | ||||||||
City: | ELK GROVE | ||||||||
State: | CA | ||||||||
PostalCode: | 957587901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166915900 | ||||||||
FaxNumber: | 9166916717 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2007 | ||||||||
LastUpdateDate: | 12/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101017533 | MI | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 20A11351 | CA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.