Provider Demographics
NPI:1639206139
Name:CHACKO, LEENA (MD)
Entity type:Individual
Prefix:MS
First Name:LEENA
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LEENA
Other - Middle Name:
Other - Last Name:LAKSHMANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:18100 NE UNION HILL RD STE 200
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3330
Practice Address - Country:US
Practice Address - Phone:206-320-5190
Practice Address - Fax:206-320-5191
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1015192Medicaid
WA2288CHOtherBLUE SHIELD
WA8475550Medicaid
WA218598OtherLABOR & INDUSTRIES
WA8475550Medicaid
WAG8864685Medicare PIN
WA2288CHOtherBLUE SHIELD