Provider Demographics
NPI:1912933151
Name:TACKETT, CHANDOS DEWAYNE (MD)
Entity Type:Individual
Prefix:
First Name:CHANDOS
Middle Name:DEWAYNE
Last Name:TACKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 US RT 60 EAST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705
Mailing Address - Country:US
Mailing Address - Phone:304-528-4663
Mailing Address - Fax:304-528-4624
Practice Address - Street 1:5170 US RT 60 EAST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705
Practice Address - Country:US
Practice Address - Phone:304-528-4663
Practice Address - Fax:304-528-4624
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0054285000Medicaid
080068402OtherRAILROAD MEDICARE
OH0141822Medicaid
OHP00472743OtherRAILROAD MEDICARE OHIO
OH0141822Medicaid
WV0054285000Medicaid
0781151Medicare PIN