Provider Demographics
NPI:1306803754
Name:KACZMAREK, ANTHONY THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:THOMAS
Last Name:KACZMAREK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 EAST HIGHWAY 72
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401
Mailing Address - Country:US
Mailing Address - Phone:573-364-1014
Mailing Address - Fax:573-364-6872
Practice Address - Street 1:1428 EAST 72HIGHWAY
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-364-1014
Practice Address - Fax:573-364-6872
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO10031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF32172Medicare UPIN