Provider Demographics
NPI:1972575470
Name:CACCAMO, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:CACCAMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 BLUE GENTIAN RD STE 1000
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1675
Mailing Address - Country:US
Mailing Address - Phone:651-683-2507
Mailing Address - Fax:651-340-1093
Practice Address - Street 1:930 BLUE GENTIAN RD STE 1000
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1675
Practice Address - Country:US
Practice Address - Phone:651-683-2507
Practice Address - Fax:651-340-1093
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN39307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN577525600Medicaid
080006688Medicare ID - Type Unspecified
MN577525600Medicaid