Provider Demographics
NPI:1780670513
Name:CACCAVALE, ALBERT G (DO)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:G
Last Name:CACCAVALE
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:PO BOX 11720
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-1720
Mailing Address - Country:US
Mailing Address - Phone:928-771-5487
Mailing Address - Fax:928-771-5471
Practice Address - Street 1:1003 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1641
Practice Address - Country:US
Practice Address - Phone:928-771-5420
Practice Address - Fax:928-771-5471
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO47673207RC0200X
AZ1944207RC0200X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
109745004OtherAPIPA
FL913113200Medicaid
CO29826551Medicaid
AZ0744400OtherBCBS
109745OtherAHCCCS
109745004OtherAPIPA
P00084227Medicare ID - Type UnspecifiedRR MEDICARE
AZ0744400OtherBCBS
77759Medicare ID - Type Unspecified
COCOA101596Medicare PIN