Provider Demographics
NPI:1538258405
Name:CHACKO, K. JOB (MD)
Entity type:Individual
Prefix:DR
First Name:K.
Middle Name:JOB
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 1:730 NORTH MAIN AVENUE
Mailing Address - Street 2:STE. 307
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205
Mailing Address - Country:US
Mailing Address - Phone:210-222-0362
Mailing Address - Fax:210-222-0598
Practice Address - Street 1:730 N MAIN AVE
Practice Address - Street 2:STE. 307
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-1152
Practice Address - Country:US
Practice Address - Phone:210-222-0362
Practice Address - Fax:210-222-0598
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7791208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics