Provider Demographics
NPI:1376814707
Name:ROY J CACCIAGUIDA MD PA
Entity Type:Organization
Organization Name:ROY J CACCIAGUIDA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CACCIAGUIDA MD PA
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:561-832-3004
Mailing Address - Street 1:7780 IRONHORSE BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33412-2423
Mailing Address - Country:US
Mailing Address - Phone:561-832-3004
Mailing Address - Fax:561-833-0460
Practice Address - Street 1:1500 N DIXIE HWY STE 201
Practice Address - Street 2:201
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2716
Practice Address - Country:US
Practice Address - Phone:561-832-3004
Practice Address - Fax:561-833-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME019768302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55757Medicare UPIN