Provider Demographics
NPI:1730348269
Name:CHANG, MARISA C (MD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:C
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-794-1870
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLAZA
Practice Address - Street 2:SUITE B200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-794-1870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA933232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A93323Medicaid
CA00A93323Medicaid