Basic Information
| Provider Information | |||||||||
| NPI: | 1265449136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KACZMAR | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1033 LOS PALOS DR | ||||||||
| Address2: | |||||||||
| City: | SALINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939013916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317572058 | ||||||||
| FaxNumber: | 8317570232 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 SAN JOSE ST | ||||||||
| Address2: | |||||||||
| City: | SALINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939013901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314240807 | ||||||||
| FaxNumber: | 8314243408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 05/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | G546380 | CA | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | ZZZ70373Z | 05 | CA | MEDICAID | 94170316793901A002 | 01 | TRICARE | OTHER |