Provider Demographics
NPI:1730265224
Name:KATHERINE CHANG, M.D.
Entity type:Organization
Organization Name:KATHERINE CHANG, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-440-3131
Mailing Address - Street 1:11999 SAN VICENTE BLVD
Mailing Address - Street 2:STE. 440
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5131
Mailing Address - Country:US
Mailing Address - Phone:310-440-3131
Mailing Address - Fax:
Practice Address - Street 1:2121 WILSHIRE BLVD
Practice Address - Street 2:STE. 201
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5720
Practice Address - Country:US
Practice Address - Phone:310-319-8592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
G53114207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G531140Medicaid
CAG53114Medicare PIN