Provider Demographics
NPI:1073661310
Name:KACZENSKI, GREGORY STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:STEPHEN
Last Name:KACZENSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 KAVANAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4323
Mailing Address - Country:US
Mailing Address - Phone:501-221-7238
Mailing Address - Fax:501-221-7239
Practice Address - Street 1:801 SCOTT ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-4613
Practice Address - Country:US
Practice Address - Phone:501-221-7238
Practice Address - Fax:501-221-7239
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5000103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104751001Medicaid
AR52787Medicare PIN
ARB90337Medicare UPIN