Provider Demographics
NPI:1558437541
Name:CACERES MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:CACERES MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:CACERES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-821-8588
Mailing Address - Street 1:8585 KNOTT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3896
Mailing Address - Country:US
Mailing Address - Phone:714-821-4482
Mailing Address - Fax:
Practice Address - Street 1:8585 KNOTT AVE STE 101
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3896
Practice Address - Country:US
Practice Address - Phone:714-821-4482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA72193OtherDR GONZALES LIC NUMBER
CA00A897280Medicaid
CAA47901OtherDR CACERES LIC NUMBER
ARA89728OtherDR CAMARILLO LIC NUMBER
CA00A479010Medicaid
CAGR0098890Medicaid
CAZZZ09814ZOtherBLUE SHEILD GRP NUM
ARA89728OtherDR CAMARILLO LIC NUMBER
CA=========OtherGRP TAX ID NUMBER
CAH76988Medicare UPIN
CAWA47901BMedicare ID - Type UnspecifiedDR CACERES INDIV MCR NUM
CAGR0098890Medicaid
CA00A479010Medicaid
CAA72193OtherDR GONZALES LIC NUMBER