Healthcare Provider Details

I. General information

NPI: 1922380708
Provider Name (Legal Business Name): PRAVEEN CHAVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42121 US HWY 70
PORTALES NM
88130-9347
US

IV. Provider business mailing address

PO BOX 299
PORTALES NM
88130-0299
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-6652
  • Fax: 575-359-6827
Mailing address:
  • Phone: 575-356-6652
  • Fax: 575-359-6827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN8280
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2013-0397
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: