Provider Demographics
NPI:1417236860
Name:KACZKOWSKI, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:KACZKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5528
Mailing Address - Country:US
Mailing Address - Phone:501-265-0100
Mailing Address - Fax:501-265-0102
Practice Address - Street 1:3924 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-265-0100
Practice Address - Fax:501-265-0102
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologist