MEDICARE: LISA CHACKO GHOSH MD

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	L7618	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8W2029	OTHER		BCBS

General Provider Information

NPI Number	:	1578511150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA CHACKO GHOSH MD

Provider Business Mailing Address
First Line	:	4755 ALDINE MAIL ROUTE
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77039-5934
Country	:	US
Telephone Number	:	281-985-7676
Fax Number	:

Provider Business Practice Location Address
First Line	:	4755 ALDINE MAIL ROUTE
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77039-5934
Country	:	US
Telephone Number	:	281-985-7676
Fax Number	:

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	02/25/2008

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