Provider Demographics
NPI:1588763072
Name:KACZMAREK, NORMAN R (MD)
Entity type:Individual
Prefix:
First Name:NORMAN
Middle Name:R
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 1:539 HARKLE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4782
Mailing Address - Country:US
Mailing Address - Phone:505-988-9769
Mailing Address - Fax:505-989-8078
Practice Address - Street 1:539 HARKLE RD
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4782
Practice Address - Country:US
Practice Address - Phone:505-988-9769
Practice Address - Fax:505-989-8078
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78-43207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000029991Medicaid
NM000029991Medicaid
NM2-12576-9Medicare ID - Type Unspecified