Basic Information
| Provider Information | |||||||||
| NPI: | 1982891362 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEO CHACKO MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6023 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730706023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183299153 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 N PORTER AVE | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053071000 | ||||||||
| FaxNumber: | 4053076660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2007 | ||||||||
| LastUpdateDate: | 03/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHACKO | ||||||||
| AuthorizedOfficialFirstName: | GEO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9183299153 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 23682 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200021120B | 05 | OK | MEDICAID |