Healthcare Provider Details

I. General information

NPI: 1558775825
Provider Name (Legal Business Name): PEIYUN CHANG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JESSE CHANG D.O.

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 PROSPECT AVE
WEST ORANGE NJ
07052
US

IV. Provider business mailing address

328 W SAINT GEORGES AVE
LINDEN NJ
07036-5638
US

V. Phone/Fax

Practice location:
  • Phone: 973-731-6767
  • Fax: 973-731-9881
Mailing address:
  • Phone: 908-925-7519
  • Fax: 908-925-2842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB09943600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: