Basic Information
| Provider Information | |||||||||
| NPI: | 1629115993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHACKO | ||||||||
| FirstName: | LYSSA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 CLERMONT ST # MS 111E | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033998020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 CLERMONT ST # MS 111E | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033998020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD431382 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1019975240001 | 05 | PA | MEDICAID |