Provider Demographics
NPI:1912469602
Name:CHAKRABARTY, SHASHWATA (DO)
Entity Type:Individual
Prefix:DR
First Name:SHASHWATA
Middle Name:
Last Name:CHAKRABARTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 MANCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8403
Mailing Address - Country:US
Mailing Address - Phone:817-233-4383
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE STE K230
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3104
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT9655207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program