Provider Demographics
NPI:1265788228
Name:CHANG, JUSTIN (DO, FAAHPM)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DO, FAAHPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8690 SIERRA COLLEGE BLVD STE 160-306
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-5961
Mailing Address - Country:US
Mailing Address - Phone:822-332-8896
Mailing Address - Fax:512-777-3130
Practice Address - Street 1:517 3RD ST STE 2
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-0460
Practice Address - Country:US
Practice Address - Phone:707-442-5683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1879207Q00000X, 171100000X
PAOS016066207Q00000X
CA20A18091207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
13526128OtherCAQH
NV1265788228Medicaid
NVV111040Medicare PIN
NVV111039Medicare PIN