Provider Demographics
NPI:1063459113
Name:KAKUSKA, DANIEL WADE (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WADE
Last Name:KAKUSKA
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 1:214 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-6208
Mailing Address - Country:US
Mailing Address - Phone:410-517-2690
Mailing Address - Fax:
Practice Address - Street 1:600 WYNDHURST AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2489
Practice Address - Country:US
Practice Address - Phone:410-517-2690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD420672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF46759Medicare UPIN
MD112RMedicare ID - Type Unspecified