Provider Demographics
NPI:1053410027
Name:CHANG, JACQUELINE A (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:A
Last Name:CHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9898 GENESEE AVE # AMP615
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1205
Mailing Address - Country:US
Mailing Address - Phone:858-824-5404
Mailing Address - Fax:858-964-3129
Practice Address - Street 1:9898 GENESEE AVE # AMP615
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-824-5404
Practice Address - Fax:858-964-3129
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80136207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110180430OtherRAILROAD MEDICARE
F569OtherCHAMPUS
CA00G801360Medicaid
CA00G801360Medicaid
CAG82930Medicare UPIN