Healthcare Provider Details

I. General information

NPI: 1063800027
Provider Name (Legal Business Name): CACIOPPO PLASTIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2014
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 N ILLINOIS ST SUITE 245
CARMEL IN
46032-3008
US

IV. Provider business mailing address

11308 ABBITT TRL
ZIONSVILLE IN
46077-0016
US

V. Phone/Fax

Practice location:
  • Phone: 317-600-8950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01061643A
License Number StateIN

VIII. Authorized Official

Name: JASON CACIOPPO
Title or Position: OWNER
Credential: M.D.
Phone: 317-600-8950