Provider Demographics
NPI:1538439559
Name:NEBU, CHACKO (MD)
Entity type:Individual
Prefix:DR
First Name:CHACKO
Middle Name:
Last Name:NEBU
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 1:8450 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3306
Mailing Address - Country:US
Mailing Address - Phone:772-871-0055
Mailing Address - Fax:772-365-0456
Practice Address - Street 1:7025 OLEANDER AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-9028
Practice Address - Country:US
Practice Address - Phone:609-744-4133
Practice Address - Fax:772-882-5166
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 111310208D00000X
FLME111310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004776500Medicaid