Basic Information
| Provider Information | |||||||||
| NPI: | 1831185941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TCHETGEN | ||||||||
| FirstName: | MARIE BLANCHE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE STE 1205 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146928262 | ||||||||
| FaxNumber: | 2145132059 | ||||||||
| Practice Location | |||||||||
| Address1: | 4370 MEDICAL ARTS DR STE 340 | ||||||||
| Address2: | |||||||||
| City: | FLOWER MOUND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723944500 | ||||||||
| FaxNumber: | 2145132059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | L3497 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 338520504 | 05 | TX | MEDICAID | 338520505 | 05 | TX | MEDICAID |