MEDICARE: CHERYL CHACKO THAMARAVELIL M. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	43613	KY
2	207VX0000X	Obstetrics Physician	P4033	TX
3	207Q00000X	Family Medicine Physician	P4033	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P4033	OTHER	TX	LICENSE

General Provider Information

NPI Number	:	1245461177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL CHACKO THAMARAVELIL M. D.

Provider Business Mailing Address
First Line	:	3639 HOLMES ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-3605
Country	:	US
Telephone Number	:	972-354-8712
Fax Number	:	972-354-8728

Provider Business Practice Location Address
First Line	:	3639 HOLMES ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-3605
Country	:	US
Telephone Number	:	972-354-8712
Fax Number	:	972-354-8728

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2009
Last Update Date	:	02/26/2025

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