Provider Demographics
NPI:1568451797
Name:CHANG, PETER TAE-JIN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:TAE-JIN
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 4771
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4771
Mailing Address - Country:US
Mailing Address - Phone:713-798-6100
Mailing Address - Fax:713-798-4082
Practice Address - Street 1:1977 BUTLER BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4101
Practice Address - Country:US
Practice Address - Phone:713-798-6100
Practice Address - Fax:713-798-4082
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8645207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1038135OtherBLUE LINK
TX8G7723OtherBC/BS
TX165744702Medicaid
TX165744701Medicaid
TX8C1196Medicare PIN
TX1038135OtherBLUE LINK
H96802Medicare UPIN
TX8B9375Medicare PIN
TX8G7723OtherBC/BS