Provider Demographics
NPI:1528337391
Name:CHACKO, ELIZABETH (DO)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7106 RIDGE RD STE B
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3883
Mailing Address - Country:US
Mailing Address - Phone:443-777-6351
Mailing Address - Fax:877-423-2285
Practice Address - Street 1:7106 RIDGE RD STE B
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3883
Practice Address - Country:US
Practice Address - Phone:443-777-6351
Practice Address - Fax:877-423-2285
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0166029051207R00000X, 390200000X
MDH86512207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program