Provider Demographics
NPI:1801189055
Name:ACHANKUNJU A CHACKO MD LLC
Entity Type:Organization
Organization Name:ACHANKUNJU A CHACKO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ACHANKUNJU
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:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD20129261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7959214000Medicaid
C62684Medicare UPIN
415989Medicare PIN