Provider Demographics
NPI:1386719318
Name:CACCAVALE, ROBERT JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:CACCAVALE
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 1:35 CLYDE ROAD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873
Mailing Address - Country:US
Mailing Address - Phone:732-247-3002
Mailing Address - Fax:732-846-3819
Practice Address - Street 1:35 CLYDE ROAD
Practice Address - Street 2:SUITE #104
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873
Practice Address - Country:US
Practice Address - Phone:732-247-3002
Practice Address - Fax:732-846-3819
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05123900208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0448206Medicaid
E53523Medicare UPIN
NJ0448206Medicaid