Healthcare Provider Details

I. General information

NPI: 1326164872
Provider Name (Legal Business Name): SHEEBU V CHACKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 FANIN ST PEM DEPT A210
HOUSTON TX
77030-2303
US

IV. Provider business mailing address

4543 ROYAL BEND LN
SUGAR LAND TX
77479-1565
US

V. Phone/Fax

Practice location:
  • Phone: 832-824-5497
  • Fax: 832-825-5424
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number242169
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: