Basic Information
| Provider Information | |||||||||
| NPI: | 1366426264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | YOUK-TWOO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 FIELDCREST DR | ||||||||
| Address2: | |||||||||
| City: | NEW CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109565439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456238400 | ||||||||
| FaxNumber: | 8456232451 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 OLD TURNPIKE RD | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | NANUET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109542461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456238400 | ||||||||
| FaxNumber: | 8456232451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 12/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 171437 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 01632535 | 05 | NY | MEDICAID |