Provider Demographics
NPI:1700842440
Name:CHACKO, GEO PHILIPS (MD)
Entity Type:Individual
Prefix:DR
First Name:GEO PHILIPS
Middle Name:
Last Name:CHACKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GEO
Other - Middle Name:
Other - Last Name:CHACKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6023
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-6023
Mailing Address - Country:US
Mailing Address - Phone:405-307-6630
Mailing Address - Fax:405-307-6660
Practice Address - Street 1:901 N PORTER AVE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6404
Practice Address - Country:US
Practice Address - Phone:405-307-6630
Practice Address - Fax:405-307-6660
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200021120AMedicaid
H45952Medicare UPIN
OK4000522350Medicare ID - Type Unspecified