Healthcare Provider Details

I. General information

NPI: 1578772687
Provider Name (Legal Business Name): ROGER KAKOS KAKOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST
DETROIT MI
48201-2153
US

IV. Provider business mailing address

14470 LABELLE ST
OAK PARK MI
48237-1148
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-5009
  • Fax:
Mailing address:
  • Phone: 248-842-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301086248
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301086248
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301086248
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: