Provider Demographics
NPI:1679778005
Name:CACERES, MARCO ANTONIO SR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:ANTONIO
Last Name:CACERES
Suffix:SR
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 1:110 WALTER AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-1609
Mailing Address - Country:US
Mailing Address - Phone:252-537-7084
Mailing Address - Fax:
Practice Address - Street 1:244 SMITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4956
Practice Address - Country:US
Practice Address - Phone:252-535-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-16
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC196762083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8920639Medicaid