Provider Demographics
NPI:1437167590
Name:CHANG, WOOTAEK
Entity Type:Individual
Prefix:
First Name:WOOTAEK
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1434
Mailing Address - Country:US
Mailing Address - Phone:516-365-1822
Mailing Address - Fax:718-250-6179
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5425
Practice Address - Country:US
Practice Address - Phone:718-250-8022
Practice Address - Fax:718-250-6179
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171373207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01153222Medicaid
NYE87319Medicare UPIN
NY01153222Medicaid
NY35F221Medicare PIN