Healthcare Provider Details

I. General information

NPI: 1659651552
Provider Name (Legal Business Name): CHAITANYA GOUD BONDA M.D., MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 MEDICAL CENTER PKWY STE 310
BENTONVILLE AR
72712-3204
US

IV. Provider business mailing address

5375 COIT RD STE 130
FRISCO TX
75035-4914
US

V. Phone/Fax

Practice location:
  • Phone: 479-553-3310
  • Fax: 479-553-1947
Mailing address:
  • Phone: 479-553-3310
  • Fax: 479-553-1947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberS8421
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: