Basic Information
| Provider Information | |||||||||
| NPI: | 1568451797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | TAE-JIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4771 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137986100 | ||||||||
| FaxNumber: | 7137984082 | ||||||||
| Practice Location | |||||||||
| Address1: | 1977 BUTLER BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137986100 | ||||||||
| FaxNumber: | 7137984082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0009X | L8645 | TX | N | 207W00000X | L8645 | TX | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1038135 | 01 | TX | BLUE LINK | OTHER | 8G7723 | 01 | TX | BC/BS | OTHER | 165744702 | 05 | TX | MEDICAID | 165744701 | 05 | TX | MEDICAID |