Provider Demographics
NPI:1689171472
Name:BENJAMIN, BUSH CHACKO (MD, MBA)
Entity Type:Individual
Prefix:
First Name:BUSH
Middle Name:CHACKO
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:BUSH
Other - Middle Name:CHACKO
Other - Last Name:BENCHAMIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2840 LEGACY DR STE 400
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6055
Mailing Address - Country:US
Mailing Address - Phone:469-200-6100
Mailing Address - Fax:
Practice Address - Street 1:2840 LEGACY DR STE 400
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-6055
Practice Address - Country:US
Practice Address - Phone:469-200-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT0056207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program