Healthcare Provider Details

I. General information

NPI: 1245720259
Provider Name (Legal Business Name): KEVIN K CHACKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4649 SEABISCUIT ST
CARROLLTON TX
75010-4206
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 214-938-6605
  • Fax:
Mailing address:
  • Phone: 682-885-6483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10064499
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT2840
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: