Provider Demographics
NPI:1154589612
Name:STONEBROOK FAMILY MEDICINE
Entity type:Organization
Organization Name:STONEBROOK FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-712-1911
Mailing Address - Street 1:8200 STONEBROOK PKWY
Mailing Address - Street 2:#100
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-5539
Mailing Address - Country:US
Mailing Address - Phone:972-712-1911
Mailing Address - Fax:
Practice Address - Street 1:8200 STONEBROOK PKWY
Practice Address - Street 2:#100
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-5539
Practice Address - Country:US
Practice Address - Phone:972-712-1911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH98210Medicare UPIN
TX610144Medicare PIN