Provider Demographics
NPI:1720417397
Name:CACCAMO, KEVIN ANTHONY
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANTHONY
Last Name:CACCAMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5137 E 1100 S # 2
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE
Mailing Address - State:IN
Mailing Address - Zip Code:46759-9752
Mailing Address - Country:US
Mailing Address - Phone:260-346-2961
Mailing Address - Fax:260-346-2961
Practice Address - Street 1:5137 E 1100 S # 2
Practice Address - Street 2:
Practice Address - City:KEYSTONE
Practice Address - State:IN
Practice Address - Zip Code:46759-9752
Practice Address - Country:US
Practice Address - Phone:260-346-2961
Practice Address - Fax:260-346-2961
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8926571882347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201167230AMedicaid