1932456605 NPI number — DR. MARY ANNE SAPNA CHACKO M.D., PHD

Table of content: DR. MARY ANNE SAPNA CHACKO M.D., PHD (NPI 1932456605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932456605 NPI number — DR. MARY ANNE SAPNA CHACKO M.D., PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHACKO
Provider First Name:
MARY ANNE
Provider Middle Name:
SAPNA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MANI
Provider Other First Name:
MARY ANNE
Provider Other Middle Name:
SAPNA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D., PHD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932456605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4716 HOLLY TREE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75287-7219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-799-0560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1441 N BECKLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75203-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-947-2306
Provider Business Practice Location Address Fax Number:
214-947-2358
Provider Enumeration Date:
08/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  BP 10043391 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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