Provider Demographics
NPI:1245382795
Name:CHACON OSORIO, GINA (MD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CHACON OSORIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-353-4830
Mailing Address - Fax:517-432-3145
Practice Address - Street 1:4650 S HAGADORN RD STE 100
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5386
Practice Address - Country:US
Practice Address - Phone:517-353-4830
Practice Address - Fax:517-432-3145
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN69704207R00000X
WI60883207R00000X
FLTRN8929207R00000X
MI4301092791207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245382795Medicaid
MI0C36082Medicare PIN
MIC36082113Medicare PIN