Timothy Wallace Kaczmar, M.D.
Individual provider Active NPI Family Medicine Physician · Eldridge, CA
NPI 1447244405 · NPPES record last updated Nov 17, 2016
Key facts
- NPI
- 1447244405
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- G68791 (CA)
- Practice address
- 15000 Arnold Dr
Eldridge, CA 95431-8900 - Phone
- (707) 938-6000
- NPI assigned
- Sep 7, 2005
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 68791 | CA | MD | Mental Health Counselor |
| G68791 | CA | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| State of California - Department of Developmental Services | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | G68791 | CA | Yes |
Addresses
Primary practice location
15000 Arnold Dr
Eldridge, CA 95431-8900
Mailing address
15000 Arnold Dr
Eldridge, CA 95431-8900
Phone (707) 938-6000
Other providers in Eldridge, CA
All providers in Eldridge, CA · Family Medicine Physician in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 17, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.