Provider Demographics
NPI:1407956907
Name:CHACKO, MATHEW MELOOTTU (MD)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:MELOOTTU
Last Name:CHACKO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:222 E MAIN ST
Mailing Address - Street 2:SIUTE 101
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2871
Mailing Address - Country:US
Mailing Address - Phone:631-360-0303
Mailing Address - Fax:631-360-2815
Practice Address - Street 1:222 E MAIN ST
Practice Address - Street 2:SIUTE 101
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2871
Practice Address - Country:US
Practice Address - Phone:631-360-0303
Practice Address - Fax:631-360-2815
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1491742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00893614Medicaid
NY00893614Medicaid
NYCO9698Medicare UPIN