Provider Demographics
NPI:1891809943
Name:KENNETH M. CALDWELL, MD, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:KENNETH M. CALDWELL, MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-284-5300
Mailing Address - Street 1:8 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549
Mailing Address - Country:US
Mailing Address - Phone:925-284-5300
Mailing Address - Fax:925-962-9561
Practice Address - Street 1:3717 MT DIABLO BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3547
Practice Address - Country:US
Practice Address - Phone:925-284-5300
Practice Address - Fax:925-284-5381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22558207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A225581Medicaid
CAZZZ01562ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
CA00A225581Medicaid