Provider Demographics
NPI:1972695872
Name:CHACKO, JOHN KABZEEL YESUDAS (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KABZEEL YESUDAS
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 1:3212 CHURCHLAND BOULEVARD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321
Mailing Address - Country:US
Mailing Address - Phone:757-399-0886
Mailing Address - Fax:757-399-1191
Practice Address - Street 1:3212 CHURCHLAND BOULEVARD
Practice Address - Street 2:SUITE 8
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5206
Practice Address - Country:US
Practice Address - Phone:757-399-0886
Practice Address - Fax:757-399-1191
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037065208600000X, 2086S0129X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA174596OtherANTHEM BC BS
VA15421OtherOPTIMA
VAB59983Medicare UPIN
VA00W344E01Medicare ID - Type Unspecified