Provider Demographics
NPI:1922167303
Name:CHACKO, DAVID M (MD, PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:CHACKO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:655 N WOODLAWN
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208
Practice Address - Country:US
Practice Address - Phone:316-684-5158
Practice Address - Fax:316-681-1005
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS0429173207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS180043551OtherRAILROAD MEDICARE
KS100143410BMedicaid
KS101131Medicare PIN
KS100143410BMedicaid