Provider Demographics
NPI:1508878414
Name:CHACKO, ACHANKUNJU A (MD)
Entity Type:Individual
Prefix:
First Name:ACHANKUNJU
Middle Name:A
Last Name:CHACKO
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 1:7610 CARROLL AVE
Mailing Address - Street 2:SUITE # 390
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6384
Mailing Address - Country:US
Mailing Address - Phone:301-270-5522
Mailing Address - Fax:301-270-4837
Practice Address - Street 1:7610 CARROLL AVE
Practice Address - Street 2:SUITE # 390
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6384
Practice Address - Country:US
Practice Address - Phone:301-270-5522
Practice Address - Fax:301-270-4837
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD20129207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7959214000Medicaid
415989Medicare ID - Type Unspecified
MD7959214000Medicaid