Provider Demographics
NPI:1578511150
Name:GHOSH, LISA CHACKO (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CHACKO
Last Name:GHOSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 ALDINE MAIL ROUTE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77039-5934
Mailing Address - Country:US
Mailing Address - Phone:281-985-7676
Mailing Address - Fax:
Practice Address - Street 1:4755 ALDINE MAIL ROUTE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77039-5934
Practice Address - Country:US
Practice Address - Phone:281-985-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7618207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8W2029OtherBCBS
TXI06216Medicare UPIN
TX8J1558Medicare PIN