Healthcare Provider Details

I. General information

NPI: 1366556995
Provider Name (Legal Business Name): PROSANTI K CHOWDHURY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6316 PRECINCT LINE RD
HURST TX
76054-2766
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 817-605-2504
  • Fax: 817-605-2505
Mailing address:
  • Phone: 682-885-1860
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH7547
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: