Provider Demographics
NPI:1811209224
Name:CHACKO, SNEHA (MD)
Entity type:Individual
Prefix:DR
First Name:SNEHA
Middle Name:
Last Name:CHACKO
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 1:401 WOODLAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-8797
Mailing Address - Country:US
Mailing Address - Phone:620-223-7070
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY276255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0000000OtherBLHC FAMILY MEDICINE RESIDENCY PROGRAM