Provider Demographics
NPI:1760554364
Name:KACKA, MICHAEL JOHN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:KACKA
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:3209 COLONIAL DR
Mailing Address - Street 2:PALMETTO HEALTH PREVENTIVE MEDICINE RESIDENCY
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6930
Mailing Address - Country:US
Mailing Address - Phone:803-434-6113
Mailing Address - Fax:803-434-7231
Practice Address - Street 1:3209 COLONIAL DR
Practice Address - Street 2:PALMETTO HEALTH PREVENTIVE MEDICINE RESIDENCY
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6930
Practice Address - Country:US
Practice Address - Phone:803-434-6113
Practice Address - Fax:803-434-7231
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-09-24
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Provider Licenses
StateLicense IDTaxonomies
SCMD383812083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine