Provider Demographics
NPI:1477503936
Name:CHANG, THEODORE T (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:T
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:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:319 S MANNING BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1742
Practice Address - Country:US
Practice Address - Phone:518-438-1019
Practice Address - Fax:518-438-0981
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-02-07
Deactivation Date:2024-01-31
Deactivation Code:
Reactivation Date:2024-02-07
Provider Licenses
StateLicense IDTaxonomies
NY204809-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00406922007OtherBLUE SHIELD NORTHEASTERN
NY1099057OtherGHI PPO
NYP00291584OtherRAILROAD MEDICARE
NY92950OtherGHI HMO
NY10002480OtherCAPITAL DISTRICT PHYSICIA
NY24134OtherMOHAWK VALLEY PHYSICIANS
NY10002480OtherCAPITAL DISTRICT PHYSICIA
NY1099057OtherGHI PPO