Provider Demographics
NPI:1598429219
Name:KACULINI, MICKAEL DAVID (OD)
Entity Type:Individual
Prefix:
First Name:MICKAEL
Middle Name:DAVID
Last Name:KACULINI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 RICCIUTI DR APT 632
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-6294
Mailing Address - Country:US
Mailing Address - Phone:832-449-0493
Mailing Address - Fax:
Practice Address - Street 1:200 WESTGATE DR STE E133
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1885
Practice Address - Country:US
Practice Address - Phone:508-587-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5511152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist