Provider Demographics
NPI:1255378675
Name:VIJAY CHAKU
Entity type:Organization
Organization Name:VIJAY CHAKU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAKU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-791-2512
Mailing Address - Street 1:3085 HALLMARK CT
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-6803
Mailing Address - Country:US
Mailing Address - Phone:989-791-2512
Mailing Address - Fax:
Practice Address - Street 1:3085 HALLMARK CT
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-6803
Practice Address - Country:US
Practice Address - Phone:989-791-2512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVC046248207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2725830Medicaid
MI2725830Medicaid
MIE82655Medicare UPIN