Provider Demographics
NPI:1043662158
Name:CHANG, KRISTINA EUNJEONG (DPM)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:EUNJEONG
Last Name:CHANG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5279 E THE TOLEDO
Mailing Address - Street 2:#4
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-1862
Mailing Address - Country:US
Mailing Address - Phone:661-863-8620
Mailing Address - Fax:
Practice Address - Street 1:3700 E SOUTH STREET
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90805
Practice Address - Country:US
Practice Address - Phone:562-531-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEL6769213E00000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery