Provider Demographics
NPI:1831185941
Name:TCHETGEN, MARIE BLANCHE N (MD)
Entity type:Individual
Prefix:
First Name:MARIE BLANCHE
Middle Name:N
Last Name:TCHETGEN
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 1:3600 GASTON AVE STE 1205
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1812
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-513-2059
Practice Address - Street 1:4370 MEDICAL ARTS DR STE 340
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:972-394-4500
Practice Address - Fax:214-513-2059
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL34972088F0040X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088F0040XAllopathic & Osteopathic PhysiciansUrologyUrogynecology and Reconstructive Pelvic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX338520505Medicaid
TX338520504Medicaid
TX149209205OtherMEDICAID - DALLAS
TX149209205OtherMEDICAID - DALLAS
TX149209206OtherMEDICAID - OTHER
TX8036J8Medicare PIN
TX149209204OtherMEDICAID - TARRANT
TX149209204Medicaid
TX8G1681Medicare PIN