Provider Demographics
NPI:1487752168
Name:CHANG, BOGARD (OD)
Entity type:Individual
Prefix:DR
First Name:BOGARD
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 W EAST CREST WAY
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-3719
Mailing Address - Country:US
Mailing Address - Phone:626-284-9771
Mailing Address - Fax:
Practice Address - Street 1:1711 W TEMPLE ST FL 7
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5421
Practice Address - Country:US
Practice Address - Phone:213-413-8213
Practice Address - Fax:213-413-2879
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11253TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0112531Medicaid
CAU79791Medicare UPIN
CAOP11253AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER