Provider Demographics
NPI:1346340551
Name:CHACKO, JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:CHACKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13627
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85732-3627
Mailing Address - Country:US
Mailing Address - Phone:520-575-6944
Mailing Address - Fax:520-575-1115
Practice Address - Street 1:2055 W HOSPITAL DR STE 205
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7822
Practice Address - Country:US
Practice Address - Phone:520-575-6944
Practice Address - Fax:520-575-1115
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26484207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z5260OtherHEALTHNET
AZAZ0874840OtherBCBS
AZ509961Medicaid
AZAZ0874840OtherBCBS
AZZ63005Medicare PIN