Provider Demographics
NPI:1063468908
Name:CHOWPAKNAM, GRIENGSAK (MD)
Entity Type:Individual
Prefix:
First Name:GRIENGSAK
Middle Name:
Last Name:CHOWPAKNAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-2438
Mailing Address - Country:US
Mailing Address - Phone:806-796-0507
Mailing Address - Fax:806-799-6908
Practice Address - Street 1:2200 N BRYAN AVE
Practice Address - Street 2:
Practice Address - City:LAMESA
Practice Address - State:TX
Practice Address - Zip Code:79331-2451
Practice Address - Country:US
Practice Address - Phone:806-872-6525
Practice Address - Fax:806-872-6550
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4793208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137332612Medicaid