Provider Demographics
NPI:1629115993
Name:CHACKO, LYSSA N (MD)
Entity Type:Individual
Prefix:
First Name:LYSSA
Middle Name:N
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 1:1055 CLERMONT ST # MS 111E
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-3808
Mailing Address - Country:US
Mailing Address - Phone:303-399-8020
Mailing Address - Fax:
Practice Address - Street 1:1055 CLERMONT ST # MS 111E
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3808
Practice Address - Country:US
Practice Address - Phone:303-399-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD431382207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019975240001Medicaid
PA115231JH4Medicare PIN