Provider Demographics
NPI:1871567727
Name:KIM, CHANG S (MD)
Entity type:Individual
Prefix:DR
First Name:CHANG
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 2920
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-2920
Mailing Address - Country:US
Mailing Address - Phone:805-461-7080
Mailing Address - Fax:805-464-0243
Practice Address - Street 1:1310 LAS TABLAS RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9737
Practice Address - Country:US
Practice Address - Phone:805-461-7080
Practice Address - Fax:805-464-0243
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA341562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A341560Medicaid
A27396Medicare UPIN
CA00A341560Medicaid