=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972575470
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID J CACCAMO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2006
-----------------------------------------------------
Last Update Date | 09/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 930 BLUE GENTIAN RD STE 1000
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55121-1675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-683-2507
-----------------------------------------------------
Fax | 651-340-1093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 BLUE GENTIAN RD STE 1000
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55121-1675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-683-2507
-----------------------------------------------------
Fax | 651-340-1093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 39307
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------