Provider Demographics
NPI:1962485045
Name:CACKOVIC, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CACKOVIC
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 1:395 W 12TH AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:614-293-9269
Mailing Address - Fax:614-293-5877
Practice Address - Street 1:1800 ZOLLINGER RD FL 4
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2800
Practice Address - Country:US
Practice Address - Phone:614-293-2222
Practice Address - Fax:614-293-2200
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043635207V00000X
OH35.099633207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0068451Medicaid
OHH148079Medicare PIN
I43493Medicare UPIN