Provider Demographics
NPI:1366460941
Name:CHOUSAND, MAXI THEODORINE (MD)
Entity Type:Individual
Prefix:
First Name:MAXI
Middle Name:THEODORINE
Last Name:CHOUSAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEIHATI
Other - Middle Name:
Other - Last Name:SOEMIJARSIH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2561 GREEN OAK DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4224
Mailing Address - Country:US
Mailing Address - Phone:972-307-9116
Mailing Address - Fax:
Practice Address - Street 1:300 W ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4856
Practice Address - Country:US
Practice Address - Phone:817-882-6003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine