Provider Demographics
NPI:1407854169
Name:CHACKO THOMAS, DAISY (MD)
Entity Type:Individual
Prefix:DR
First Name:DAISY
Middle Name:
Last Name:CHACKO THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1669 BELVIDERE RD
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-9306
Mailing Address - Country:US
Mailing Address - Phone:815-971-3030
Mailing Address - Fax:815-971-9895
Practice Address - Street 1:1669 BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-9306
Practice Address - Country:US
Practice Address - Phone:815-971-3030
Practice Address - Fax:815-971-9895
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111218Medicaid
ILK44415Medicare PIN
I19822Medicare UPIN