Provider Demographics
NPI:1710089453
Name:KACZKOFSKY, PETER EARL DAVID (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:EARL DAVID
Last Name:KACZKOFSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9700
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2221 HEALTH DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509
Practice Address - Country:US
Practice Address - Phone:616-252-4410
Practice Address - Fax:616-252-4480
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI012006207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1654101584OtherBLUE CARE NETWORD
MI4708195Medicaid
MI4708275Medicaid
MI4708005Medicaid
MI1654101584OtherBLUE CROSS BLUE SHIELD
MI4708168Medicaid
MI4708168Medicaid
MI4708005Medicaid