Provider Demographics
NPI:1922036094
Name:CHACKO, JACOB M (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:CHACKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 890580
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0580
Mailing Address - Country:US
Mailing Address - Phone:540-427-4406
Mailing Address - Fax:540-427-4915
Practice Address - Street 1:AUGUSTA MEDICAL CENTER ANESTHESIA DEPT
Practice Address - Street 2:78 MEDICAL CENTER DRIVE
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939
Practice Address - Country:US
Practice Address - Phone:540-427-4406
Practice Address - Fax:540-427-4915
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA047726207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922036094Medicaid
VA005701457Medicaid
VA050000942Medicare PIN