Healthcare Provider Details

I. General information

NPI: 1588866297
Provider Name (Legal Business Name): CHAITANYA KUMAR MUSHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT VINCENT CIR FL 3
LITTLE ROCK AR
72205-5423
US

IV. Provider business mailing address

401 N CARROLL AVE STE 440
SOUTHLAKE TX
76092-6407
US

V. Phone/Fax

Practice location:
  • Phone: 501-552-4677
  • Fax: 501-552-4555
Mailing address:
  • Phone: 501-552-4677
  • Fax: 501-552-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ3927
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-6956
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: