Provider Demographics
NPI:1417973496
Name:CHATHAM, JOSEPH LUCKOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LUCKOSE
Last Name:CHATHAM
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 1:221 S POWER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-5205
Mailing Address - Country:US
Mailing Address - Phone:480-981-2010
Mailing Address - Fax:480-981-1771
Practice Address - Street 1:221 S POWER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-5205
Practice Address - Country:US
Practice Address - Phone:480-981-2010
Practice Address - Fax:480-981-1771
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15177207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ224634Medicaid
AZ0626556OtherAETNA
AZAZ0015400OtherBCBS
AZAZ0015400OtherBCBS
D43776Medicare UPIN