Basic Information
| Provider Information | |||||||||
| NPI: | 1225020571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHACKO | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5575 HOLLISTER AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | GOLETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931173825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059643838 | ||||||||
| FaxNumber: | 8059646946 | ||||||||
| Practice Location | |||||||||
| Address1: | 504 W PUEBLO ST | ||||||||
| Address2: | SUITE102 | ||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931056211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056877719 | ||||||||
| FaxNumber: | 8056822971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | A69285 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1225020571 | 05 | CA | MEDICAID |