Provider Demographics
NPI:1982652111
Name:CHACON, MARY T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:T
Last Name:CHACON
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 8
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627-0008
Mailing Address - Country:US
Mailing Address - Phone:787-231-1008
Mailing Address - Fax:
Practice Address - Street 1:URB. FLAMBOYAN, MARGINAL SUR B-11
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-231-1008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15730208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI36878Medicaid
PRI36878Medicare UPIN
PRI36878Medicaid