Healthcare Provider Details

I. General information

NPI: 1609309863
Provider Name (Legal Business Name): CHETAN KUMAR NANJEGOWDA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date: 11/09/2017
Reactivation Date: 11/26/2018

III. Provider practice location address

3601 4TH ST STE 4B244
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

3601 4TH ST STE 4B244
LUBBOCK TX
79430-0002
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-6478
  • Fax:
Mailing address:
  • Phone: 806-743-6478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number48957
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number48957
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: