Provider Demographics
NPI:1366485252
Name:KACZOR, JOSEPH GERARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:GERARD
Last Name:KACZOR
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 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-437-9605
Practice Address - Street 1:301 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5413
Practice Address - Country:US
Practice Address - Phone:432-335-8275
Practice Address - Fax:432-334-0687
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ48722085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124516902OtherCSHCN
TX920005366OtherRAILROAD
TX124516904Medicaid
NM000J3215Medicaid
TX124516905Medicaid
TX8R1480OtherBLUE CROSS OF TX
TX124516903Medicaid
TX8D8766Medicare PIN
TX124516904Medicaid
TX84X691Medicare PIN