Provider Demographics
NPI:1104896000
Name:KACZMAREK, LINDA (DO)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:214 S MIDLAND BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2602
Practice Address - Country:US
Practice Address - Phone:208-465-6900
Practice Address - Fax:208-465-6911
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010162602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4767365Medicaid
MI4767365Medicaid
MI0M40150101Medicare ID - Type Unspecified