Provider Demographics
NPI:1588696868
Name:CHACKO, LYNN MARIA (MD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIA
Last Name:CHACKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1223 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2607
Mailing Address - Country:US
Mailing Address - Phone:321-725-4500
Mailing Address - Fax:321-409-6813
Practice Address - Street 1:730 MALABAR RD
Practice Address - Street 2:
Practice Address - City:MALABAR
Practice Address - State:FL
Practice Address - Zip Code:32950-3140
Practice Address - Country:US
Practice Address - Phone:321-409-6800
Practice Address - Fax:321-409-6813
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME94975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275903900Medicaid
FLP00434933OtherRR MEDICARE
FLAF873ZMedicare PIN