Provider Demographics
NPI:1235189077
Name:KACZAR, PHILIP C (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:C
Last Name:KACZAR
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-838-8265
Mailing Address - Fax:702-804-3788
Practice Address - Street 1:8041 N BLACK CANYON HWY STE I
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4173
Practice Address - Country:US
Practice Address - Phone:602-249-0115
Practice Address - Fax:602-249-0838
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ22683Medicare ID - Type Unspecified
G68086Medicare UPIN