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General NPI Number Information
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NPI Number | 1104264654
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Entity Type | Individual
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Provider Name | LISA RENEE CHACKO M.D., MPH
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Gender | Female
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Dates
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Enumeration Date | 06/06/2013
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Last Update Date | 02/05/2025
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Provider Practice Location Address
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Address Line | 1707 N MAIN ST
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City | GAINESVILLE
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State | FL
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Zip | 32609-3650
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Country | US
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Telephone | 352-265-9593
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Fax |
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Provider Business Mailing Address
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Address Line | 1600 SW ARCHER RD BOX 100383
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City | GAINESVILLE
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State | FL
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Zip | 32610-0383
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Country | US
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Telephone | 352-392-4541
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME128039
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License Number State | FL
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