Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 59383 | GA |
NPI | 1356443089 |
---|---|
Provider Name | Dr. Thomas Chacko |
First Address | Alpharetta, GA 30005-4626 |
Second Address | Roswell, GA 30076-1146 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2006 |
Last Update Date | 13/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
59383 | GEORGIA MEDICAL LICENSE (01) | GA |