Basic Information
| Provider Information | |||||||||
| NPI: | 1477503936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 319 S MANNING BLVD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122081742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184381019 | ||||||||
| FaxNumber: | 5184380981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 204809-1 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00406922007 | 01 | NY | BLUE SHIELD NORTHEASTERN | OTHER | 1099057 | 01 | NY | GHI PPO | OTHER | P00291584 | 01 | NY | RAILROAD MEDICARE | OTHER | 92950 | 01 | NY | GHI HMO | OTHER | 10002480 | 01 | NY | CAPITAL DISTRICT PHYSICIA | OTHER | 24134 | 01 | NY | MOHAWK VALLEY PHYSICIANS | OTHER |