Provider Demographics
NPI:1063500163
Name:CACCIAMANI, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:CACCIAMANI
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 1:522 E 100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1905
Mailing Address - Country:US
Mailing Address - Phone:801-485-5055
Mailing Address - Fax:801-467-3296
Practice Address - Street 1:522 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1905
Practice Address - Country:US
Practice Address - Phone:801-485-5055
Practice Address - Fax:801-467-3296
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49426771205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4498Medicaid
UT000057838OtherPTAN
UT005783801Medicare ID - Type UnspecifiedPROVIDER ID#
UT000057838OtherPTAN