Healthcare Provider Details

I. General information

NPI: 1316928104
Provider Name (Legal Business Name): KEVIN JOHN CALDWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 MARSHALL ST
CRESCENT CITY CA
95531-2217
US

IV. Provider business mailing address

1240 MARSHALL ST
CRESCENT CITY CA
95531-2217
US

V. Phone/Fax

Practice location:
  • Phone: 707-465-5566
  • Fax: 707-465-4990
Mailing address:
  • Phone: 707-465-5566
  • Fax: 707-465-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG42767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: