Healthcare Provider Details

I. General information

NPI: 1326206301
Provider Name (Legal Business Name): MANJU CHACKO DAWKINS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANJU TRACY CHACKO M.D.

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5971 VENICE BLVD
LOS ANGELES CA
90034-1713
US

IV. Provider business mailing address

5971 VENICE BLVD
LOS ANGELES CA
90034-1713
US

V. Phone/Fax

Practice location:
  • Phone: 323-857-4322
  • Fax:
Mailing address:
  • Phone: 323-857-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number246191-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA121539
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberFD2807052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: