Provider Demographics
NPI:1053739391
Name:CACERES, KEVIN JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JONATHAN
Last Name:CACERES
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 1:3000 MEDICAL PARK DR STE 170
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-6601
Mailing Address - Country:US
Mailing Address - Phone:813-467-4262
Mailing Address - Fax:813-467-4264
Practice Address - Street 1:1615 PASADENA AVE S STE 220
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4517
Practice Address - Country:US
Practice Address - Phone:727-870-3223
Practice Address - Fax:727-870-4223
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1574207YS0123X, 207Y00000X
FLME145079207YS0123X, 207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program