Provider Demographics
NPI:1912999210
Name:GACA, PHILLIP JOSEPH (DO)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:JOSEPH
Last Name:GACA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6265 W RIVER RD NE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-9078
Mailing Address - Country:US
Mailing Address - Phone:616-365-7614
Mailing Address - Fax:616-364-9570
Practice Address - Street 1:6265 W RIVER RD NE
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MI
Practice Address - Zip Code:49306-9078
Practice Address - Country:US
Practice Address - Phone:616-365-7614
Practice Address - Fax:616-364-9570
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3018321Medicaid
E26484Medicare UPIN