Provider Demographics
NPI:1639371263
Name:KACZANOWSKI, MICHAEL ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:KACZANOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8 PROSPECT ST
Mailing Address - Street 2:NORTH II
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3925
Mailing Address - Country:US
Mailing Address - Phone:603-577-5355
Mailing Address - Fax:603-577-5356
Practice Address - Street 1:8 PROSPECT ST
Practice Address - Street 2:NORTH II
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3925
Practice Address - Country:US
Practice Address - Phone:603-577-5355
Practice Address - Fax:603-577-5356
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13968207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3079568Medicaid
NHRE6661OtherMEDICARE GROUP