Provider Demographics
NPI:1174313795
Name:TSCHEBOTARJEW, DANIELLE MARIE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:TSCHEBOTARJEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30575 KINGSLAND BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423-3179
Mailing Address - Country:US
Mailing Address - Phone:856-297-4380
Mailing Address - Fax:
Practice Address - Street 1:30575 KINGSLAND BLVD STE 150
Practice Address - Street 2:
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423-3179
Practice Address - Country:US
Practice Address - Phone:281-717-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1196985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine