MEDICARE: CHRISTIE U. EGBUCHUNAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	M2313	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8K4033	OTHER	TX	BLUE CROSS BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053337709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTIE U. EGBUCHUNAM MD

Provider Business Mailing Address
First Line	:	305 REGENCY PKWY
Second Line	:	SUITE 509
City	:	MANSFIELD
State	:	TX
Zip	:	76063-3794
Country	:	US
Telephone Number	:	817-453-2323
Fax Number	:	817-453-2322

Provider Business Practice Location Address
First Line	:	305 REGENCY PKWY
Second Line	:	SUITE 509
City	:	MANSFIELD
State	:	TX
Zip	:	76063-3794
Country	:	US
Telephone Number	:	817-453-2323
Fax Number	:	817-453-2322

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	01/26/2011

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