Provider Demographics
NPI:1053535906
Name:CHAKKALAKKAL, TRESA (MD)
Entity type:Individual
Prefix:
First Name:TRESA
Middle Name:
Last Name:CHAKKALAKKAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11218 APPLEVALE CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-8010
Mailing Address - Country:US
Mailing Address - Phone:718-334-6793
Mailing Address - Fax:718-334-6717
Practice Address - Street 1:653 N TOWN CENTER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0514
Practice Address - Country:US
Practice Address - Phone:702-363-3000
Practice Address - Fax:702-363-3161
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002415208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2682259Medicaid