Provider Demographics
NPI:1720017262
Name:CHACKO, SIJU T (MD)
Entity Type:Individual
Prefix:DR
First Name:SIJU
Middle Name:T
Last Name:CHACKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SIJU
Other - Middle Name:T
Other - Last Name:CHACKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9143 INDIANAPOLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2500
Mailing Address - Country:US
Mailing Address - Phone:219-972-1547
Mailing Address - Fax:219-972-1641
Practice Address - Street 1:9143 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2504
Practice Address - Country:US
Practice Address - Phone:219-972-1547
Practice Address - Fax:219-972-1641
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101193207R00000X
IN01064885A207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101193Medicaid
IN200892400Medicaid
IN200892400Medicaid
ILK25862Medicare ID - Type Unspecified
IN407750FMedicare PIN
H42972Medicare UPIN