Healthcare Provider Details

I. General information

NPI: 1265621114
Provider Name (Legal Business Name): PETER Y. CHANG, M.D., PH.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 JACKSON ST SUITE 102
RIVERSIDE CA
92503-3901
US

IV. Provider business mailing address

3975 JACKSON ST SUITE 102
RIVERSIDE CA
92503-3901
US

V. Phone/Fax

Practice location:
  • Phone: 951-359-0660
  • Fax:
Mailing address:
  • Phone: 951-359-0660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberG42520
License Number StateCA

VIII. Authorized Official

Name: DR. PETER Y. CHANG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-359-0660