Provider Demographics
NPI:1679584759
Name:CHACON, EDWARD J
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:CHACON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 LA ENTRADA RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7617
Mailing Address - Country:US
Mailing Address - Phone:505-620-9213
Mailing Address - Fax:
Practice Address - Street 1:6700 JEFFERSON ST NE
Practice Address - Street 2:SUITE D-2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4382
Practice Address - Country:US
Practice Address - Phone:505-288-3916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians