Provider Demographics
NPI:1518928126
Name:CHANG, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
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 1:6402 DRY CLIFF CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3918
Mailing Address - Country:US
Mailing Address - Phone:512-459-5158
Mailing Address - Fax:512-450-1056
Practice Address - Street 1:6402 DRY CLIFF CV
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3918
Practice Address - Country:US
Practice Address - Phone:512-459-5158
Practice Address - Fax:512-450-1056
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF54922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132497210Medicaid
TXDG697Medicaid
TX132497211Medicaid
TX128025706Medicaid
TX128025706Medicaid
TXTXB104346Medicare PIN
TX8F2671Medicare PIN
D54294Medicare UPIN
TXDG697Medicaid
TX8F2672Medicare PIN