Provider Demographics
NPI:1194245159
Name:CALDWELL, MEMORIE VANESSA (MD)
Entity type:Individual
Prefix:
First Name:MEMORIE
Middle Name:VANESSA
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6017
Mailing Address - Fax:904-450-6041
Practice Address - Street 1:6488 103RD ST STE B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7161
Practice Address - Country:US
Practice Address - Phone:904-450-6810
Practice Address - Fax:904-450-6729
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME147306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program