Provider Demographics
NPI:1831541887
Name:CHACON, ALICIA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:MARIE
Last Name:CHACON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:MARIE
Other - Last Name:KETCHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:925 N 87TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4812
Mailing Address - Country:US
Mailing Address - Phone:414-266-2020
Mailing Address - Fax:414-266-2027
Practice Address - Street 1:925 N 87TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4812
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3483-35152WP0200X
MO2016021330152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1831541887Medicaid
MO1831541887Medicaid
MO074730047Medicare PIN