Provider Demographics
NPI:1265449136
Name:KACZMAR, THEODORE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:KACZMAR
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1033 LOS PALOS DR
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-3916
Mailing Address - Country:US
Mailing Address - Phone:831-757-2058
Mailing Address - Fax:831-757-0232
Practice Address - Street 1:220 SAN JOSE ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3901
Practice Address - Country:US
Practice Address - Phone:831-424-0807
Practice Address - Fax:831-424-3408
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG546380207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ70373ZMedicaid
94170316793901A002OtherTRICARE
94170316793901A002OtherTRICARE
CAZZZ70373ZMedicaid