Provider Demographics
NPI:1790844926
Name:CHACKO, ELSAMMA (MD)
Entity Type:Individual
Prefix:
First Name:ELSAMMA
Middle Name:
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:PO BOX 351 SILVER STREET
Mailing Address - Street 2:CONNECTICUT VALLEY HOSPITAL
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-262-5867
Mailing Address - Fax:860-262-5850
Practice Address - Street 1:SILVER STREET
Practice Address - Street 2:CONNECTICUT VALLEY HOSPITAL
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-262-5867
Practice Address - Fax:860-262-5850
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0033196207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E83427Medicare UPIN