Provider Demographics
NPI:1912193285
Name:CHACKO, SHOBHA ANNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOBHA
Middle Name:ANNETTE
Last Name:CHACKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:41 MALL ROAD
Mailing Address - Street 2:LAHEY CLINIC
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-7000
Mailing Address - Fax:781-744-5378
Practice Address - Street 1:41 MALL ROAD
Practice Address - Street 2:LAHEY CLINIC
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-7000
Practice Address - Fax:781-744-5378
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA233867207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110078746AMedicaid
MA110078746AMedicaid