Provider Demographics
NPI:1972380533
Name:CACCIOLA, JOHN S
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:CACCIOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CAPTAIN PENNIMAN RD
Mailing Address - Street 2:
Mailing Address - City:EASTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02642-2754
Mailing Address - Country:US
Mailing Address - Phone:610-348-7523
Mailing Address - Fax:
Practice Address - Street 1:25 CAPTAIN PENNIMAN RD
Practice Address - Street 2:
Practice Address - City:EASTHAM
Practice Address - State:MA
Practice Address - Zip Code:02642-2754
Practice Address - Country:US
Practice Address - Phone:610-348-7523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program