Healthcare Provider Details

I. General information

NPI: 1891837787
Provider Name (Legal Business Name): GEORGE N CHACKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8224 SILVER XING
OKLAHOMA CITY OK
73132-3375
US

IV. Provider business mailing address

2714 LAMOND HILL AVE
EDMOND OK
73034-6979
US

V. Phone/Fax

Practice location:
  • Phone: 405-722-4645
  • Fax:
Mailing address:
  • Phone: 405-722-4645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number17461
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: