Healthcare Provider Details

I. General information

NPI: 1932456605
Provider Name (Legal Business Name): MARY ANNE SAPNA CHACKO M.D., PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ANNE SAPNA MANI M.D., PHD

II. Dates (important events)

Enumeration Date: 08/12/2012
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 BROAD PARK CIR N STE 114
MANSFIELD TX
76063-7824
US

IV. Provider business mailing address

2340 E TRINITY MILLS RD STE 250
CARROLLTON TX
75006-1946
US

V. Phone/Fax

Practice location:
  • Phone: 855-893-5637
  • Fax: 817-666-3873
Mailing address:
  • Phone: 817-886-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ7337
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: