Provider Demographics
NPI:1184667560
Name:CHANG, PETER Y (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:Y
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3975 JACKSON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3938
Mailing Address - Country:US
Mailing Address - Phone:951-359-0660
Mailing Address - Fax:951-359-0897
Practice Address - Street 1:3975 JACKSON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3938
Practice Address - Country:US
Practice Address - Phone:951-359-0660
Practice Address - Fax:951-359-0897
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42520390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG425200Medicaid
CAOOG425200Medicare ID - Type Unspecified
CAOOG425200Medicaid