Provider Demographics
NPI:1366421562
Name:KAKAZU, MARIO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:KAKAZU
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:PO BOX 2490
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073-2490
Mailing Address - Country:US
Mailing Address - Phone:504-762-8909
Mailing Address - Fax:504-328-0899
Practice Address - Street 1:2552 WILLIAMS BLVD
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-5538
Practice Address - Country:US
Practice Address - Phone:504-463-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05311R207P00000X
LAMD.05311R208100000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1317128Medicaid
LAG6438OtherBLUECROSS BLUESHIELD
LAG6438OtherBLUECROSS BLUESHIELD
53653Medicare PIN