Provider Demographics
NPI:1588703995
Name:CHANG, KEITH C (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:C
Last Name:CHANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 GRAND ST # 302
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4223
Mailing Address - Country:US
Mailing Address - Phone:212-965-8883
Mailing Address - Fax:212-965-8878
Practice Address - Street 1:217 GRAND ST # 302
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4223
Practice Address - Country:US
Practice Address - Phone:212-965-8883
Practice Address - Fax:212-965-8878
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193442207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY193442OtherLICENSE
NY01629038Medicaid
NY193442OtherLICENSE
NY17J871Medicare PIN