Provider Demographics
NPI:1679540793
Name:GACEK, EDWARD M (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:GACEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3909
Mailing Address - Country:US
Mailing Address - Phone:360-417-7000
Mailing Address - Fax:
Practice Address - Street 1:939 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3909
Practice Address - Country:US
Practice Address - Phone:360-417-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022939208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1110GAOtherREGENCE BLUE SHIELD RIDER
WA1008168Medicaid
110219614OtherRAILROAD MEDICARE
110219614OtherRAILROAD MEDICARE
WA1008168Medicaid