Healthcare Provider Details

I. General information

NPI: 1619111747
Provider Name (Legal Business Name): MIKE GLA CHIRACHANCHAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 CENTRAL EXPY N STE 235
ALLEN TX
75013-6135
US

IV. Provider business mailing address

1105 CENTRAL EXPY N STE 235
ALLEN TX
75013-6135
US

V. Phone/Fax

Practice location:
  • Phone: 972-747-6042
  • Fax: 972-747-6043
Mailing address:
  • Phone: 972-747-6042
  • Fax: 972-747-6043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP4555
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: