Provider Demographics
NPI:1124768718
Name:CALDWELL, THOMAS SULLIVAN
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:SULLIVAN
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:SAMMC, MCHE-EMR
Mailing Address - City:JBSA - FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-4789
Mailing Address - Fax:210-916-6654
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:SAMMC, MCHE-EMR
Practice Address - City:JBSA - FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-4789
Practice Address - Fax:210-916-6654
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
TXU7396208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider