Provider Demographics
NPI:1790192656
Name:LEELA A CHACKO MD LLC
Entity Type:Organization
Organization Name:LEELA A CHACKO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:LEELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-270-5522
Mailing Address - Street 1:7610 CARROLL AVE
Mailing Address - Street 2:SUITE 390
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6384
Mailing Address - Country:US
Mailing Address - Phone:301-270-5522
Mailing Address - Fax:301-270-4837
Practice Address - Street 1:7610 CARROLL AVE
Practice Address - Street 2:SUITE 390
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6384
Practice Address - Country:US
Practice Address - Phone:301-270-5522
Practice Address - Fax:301-270-4837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-12
Last Update Date:2014-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0038488261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD492274Medicare UPIN