Provider Demographics
NPI:1487853156
Name:CHACKO, SHINYMOL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHINYMOL
Middle Name:JOHN
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 1:7717 N ORANGE PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9323
Mailing Address - Country:US
Mailing Address - Phone:309-589-6800
Mailing Address - Fax:
Practice Address - Street 1:7717 N ORANGE PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9323
Practice Address - Country:US
Practice Address - Phone:309-589-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075416207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine