Provider Demographics
NPI:1598878787
Name:CHACKO, ANNIE (MD)
Entity Type:Individual
Prefix:
First Name:ANNIE
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 1:701 S ZARZAMORA ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5209
Mailing Address - Country:US
Mailing Address - Phone:210-358-7575
Mailing Address - Fax:210-358-7835
Practice Address - Street 1:701 S ZARZAMORA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5209
Practice Address - Country:US
Practice Address - Phone:210-358-7575
Practice Address - Fax:210-358-7835
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4641207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104838102Medicaid
TX87G554Medicare PIN
TX110191260Medicare PIN