Healthcare Provider Details

I. General information

NPI: 1972132900
Provider Name (Legal Business Name): KITAE CHANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

105 WASHINGTON ST APT 204
BRIGHTON MA
02135-4375
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-1745
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1019969
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number111712
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: