Provider Demographics
NPI:1013069806
Name:CHACONAS, THEODORE JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:JOHN
Last Name:CHACONAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TED
Other - Middle Name:JOHN
Other - Last Name:CHACONAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:747 52ND ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1809
Mailing Address - Country:US
Mailing Address - Phone:510-428-3237
Mailing Address - Fax:510-601-3979
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3237
Practice Address - Fax:510-601-3979
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG065093208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics