Healthcare Provider Details

I. General information

NPI: 1407093511
Provider Name (Legal Business Name): ELIZABETH MATHEWS CHACKO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH MATHEWS THURUTHEL M.D.

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 EAST 98TH STREET
NEW YORK NY
10029
US

IV. Provider business mailing address

2 CLEARMEADOW LN
WOODBURY NY
11797-1116
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-8210
  • Fax: 484-664-7864
Mailing address:
  • Phone: 516-603-9061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD453912
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number249237-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: