Provider Demographics
NPI:1902999055
Name:CALDECOTT-JOHNSON, SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:CALDECOTT-JOHNSON
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 1:6626 E 75TH ST
Mailing Address - Street 2:500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DR
Practice Address - Street 2:SUITE 5300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1621
Practice Address - Country:US
Practice Address - Phone:317-621-0104
Practice Address - Fax:317-621-0111
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMPORARY2081P0010X
IN01043182A2081P0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000661927OtherANTHEM
IN200014600Medicaid
INF99393Medicare UPIN
IN000000661927OtherANTHEM
INM400033538Medicare PIN