MEDICARE: MARIO KAKAZU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	05311R	LA
2	208100000X	Physical Medicine & Rehabilitation Physician	MD.05311R	LA
3	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	G6438	OTHER	LA	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1366421562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO KAKAZU M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2490
Second Line	:
City	:	MARRERO
State	:	LA
Zip	:	70073-2490
Country	:	US
Telephone Number	:	504-762-8909
Fax Number	:	504-328-0899

Provider Business Practice Location Address
First Line	:	2552 WILLIAMS BLVD
Second Line	:
City	:	KENNER
State	:	LA
Zip	:	70062-5538
Country	:	US
Telephone Number	:	504-463-3002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2006
Last Update Date	:	06/30/2021

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