Healthcare Provider Details

I. General information

NPI: 1033209853
Provider Name (Legal Business Name): KEVIN T. CASERTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 COOKS HILL RD STE E
CENTRALIA WA
98531-9162
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-330-8626
  • Fax:
Mailing address:
  • Phone: 360-330-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD00042344
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: