Provider Demographics
NPI:1417933433
Name:CHACKO, ANITA (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:CHACKO
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 1:621 S NEW BALLAS RD
Mailing Address - Street 2:STE. 674A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6831
Mailing Address - Fax:314-251-5670
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:STE. 674A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6831
Practice Address - Fax:314-251-5670
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4F012080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR4F01OtherMO LICENSE #