Provider Demographics
NPI:1891714689
Name:CACACE, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:CACACE
Suffix:
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 1:617 NAUTILUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576
Mailing Address - Country:US
Mailing Address - Phone:203-500-0969
Mailing Address - Fax:
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2805
Practice Address - Country:US
Practice Address - Phone:203-384-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036537146D00000X
SC29217207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC292178Medicaid
SCAA21578822Medicare PIN
SC292178Medicaid
CT930000546Medicare ID - Type Unspecified