Provider Demographics
NPI:1316928104
Name:CALDWELL, KEVIN JOHN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-2217
Mailing Address - Country:US
Mailing Address - Phone:707-465-5566
Mailing Address - Fax:707-465-4990
Practice Address - Street 1:1240 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-2217
Practice Address - Country:US
Practice Address - Phone:707-465-5566
Practice Address - Fax:707-465-4990
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49108Medicare UPIN
CAZZZ29212ZMedicare ID - Type UnspecifiedMEDICARE