Provider Demographics
NPI:1053303149
Name:CACCAMO, MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CACCAMO
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 1:540 LINCOLN PARK BLVD
Mailing Address - Street 2:STE 130
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6401
Mailing Address - Country:US
Mailing Address - Phone:937-297-6306
Mailing Address - Fax:937-299-6300
Practice Address - Street 1:540 LINCOLN PARK BLVD
Practice Address - Street 2:STE 130
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6401
Practice Address - Country:US
Practice Address - Phone:937-297-6306
Practice Address - Fax:937-299-6300
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-6134C2085R0202X
MI51010109162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0145033Medicaid
F46882Medicare UPIN
OH0145033Medicaid