Provider Demographics
NPI:1518963628
Name:KACZANDER, BRUCE IAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:IAN
Last Name:KACZANDER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24725 W 12 MILE RD
Mailing Address - Street 2:STE 270
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-8310
Mailing Address - Country:US
Mailing Address - Phone:248-353-9300
Mailing Address - Fax:248-353-9303
Practice Address - Street 1:24725 W 12 MILE RD
Practice Address - Street 2:STE 270
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8310
Practice Address - Country:US
Practice Address - Phone:248-353-9300
Practice Address - Fax:248-353-9303
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBK001054213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000002793OtherCAPE
MI480029296OtherTRICARE
MIC6928OtherMCARE
MI4188228Medicaid
MI503536OtherCARE CHOICE
MI104550400OtherUS DEP
MIT34322OtherHEALTH ALLIANCE PLAN
MI101509OtherGREAT LAKES
MI503536OtherPREFERRED CHOICES
MI83291OtherOMNI
MI4188228Medicaid
MI503536OtherCARE CHOICE
MI4263940001Medicare NSC