Provider Demographics
NPI:1619111747
Name:CHIRACHANCHAI, MIKE GLA (MD)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:GLA
Last Name:CHIRACHANCHAI
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 1:1105 CENTRAL EXPY N STE 235
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6135
Mailing Address - Country:US
Mailing Address - Phone:972-747-6042
Mailing Address - Fax:972-747-6043
Practice Address - Street 1:1105 CENTRAL EXPY N STE 235
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6135
Practice Address - Country:US
Practice Address - Phone:972-747-6042
Practice Address - Fax:972-747-6043
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4555207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB166875Medicare PIN
TXTXB166874Medicare PIN
TXTXB166876Medicare PIN