Healthcare Provider Details

I. General information

NPI: 1508878414
Provider Name (Legal Business Name): ACHANKUNJU A CHACKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 CARROLL AVE SUITE # 390
TAKOMA PARK MD
20912-6384
US

IV. Provider business mailing address

7610 CARROLL AVE SUITE # 390
TAKOMA PARK MD
20912-6384
US

V. Phone/Fax

Practice location:
  • Phone: 301-270-5522
  • Fax: 301-270-4837
Mailing address:
  • Phone: 301-270-5522
  • Fax: 301-270-4837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberD20129
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: