Provider Demographics
NPI:1609863323
Name:CHACKALACKAL, REBECCA G (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:G
Last Name:CHACKALACKAL
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:UNIVERSITY OF IOWA STUDENT HEALTH SERVICE
Mailing Address - Street 2:4189 WL
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1100
Mailing Address - Country:US
Mailing Address - Phone:319-335-8370
Mailing Address - Fax:319-335-7247
Practice Address - Street 1:UNIVERSITY OF IOWA STUDENT HEALTH SERVICE
Practice Address - Street 2:4189 WL
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1100
Practice Address - Country:US
Practice Address - Phone:319-335-8370
Practice Address - Fax:319-335-7247
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1192815Medicaid
IA55711OtherWELLMARK BCBS
IA1192815Medicaid
IAI8229Medicare PIN