Healthcare Provider Details

I. General information

NPI: 1417236860
Provider Name (Legal Business Name): MR. MICHAEL KACZKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 W MARKHAM ST
LITTLE ROCK AR
72205
US

IV. Provider business mailing address

3924 W MARKHAM ST
LITTLE ROCK AR
72205-5528
US

V. Phone/Fax

Practice location:
  • Phone: 501-265-0100
  • Fax: 501-265-0102
Mailing address:
  • Phone: 501-265-0100
  • Fax: 501-265-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code229N00000X
TaxonomyAnaplastologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: