Healthcare Provider Details

I. General information

NPI: 1881986909
Provider Name (Legal Business Name): KEVIN JOSEPH CALDWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2011
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33664 BAYVIEW MEDICAL DR UNIT 2
LEWES DE
19958-1687
US

IV. Provider business mailing address

PO BOX 19638
SPRINGFIELD IL
62794-9638
US

V. Phone/Fax

Practice location:
  • Phone: 302-644-4954
  • Fax: 302-645-5481
Mailing address:
  • Phone: 217-545-8856
  • Fax: 217-545-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number125.062550
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberC1-0012826
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: