Provider Demographics
NPI:1659462695
Name:CHAO, BO (MD)
Entity Type:Individual
Prefix:DR
First Name:BO
Middle Name:
Last Name:CHAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:625 BELLE TERRE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2316
Mailing Address - Country:US
Mailing Address - Phone:631-686-7654
Mailing Address - Fax:631-686-7653
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2119
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:631-686-7653
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241159207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI69632Medicare UPIN
NY2836S1Medicare PIN