Provider Demographics
NPI:1063434413
Name:CHACKO, JOHN T (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:CHACKO
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 1:1752 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-8170
Mailing Address - Country:US
Mailing Address - Phone:850-526-0005
Mailing Address - Fax:850-718-4261
Practice Address - Street 1:3051 6TH ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-1933
Practice Address - Country:US
Practice Address - Phone:850-526-0005
Practice Address - Fax:850-718-4261
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74735208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42842OtherBCBSFL
FLE0627AMedicare ID - Type Unspecified
FL42842OtherBCBSFL