Healthcare Provider Details

I. General information

NPI: 1982103396
Provider Name (Legal Business Name): DUSTIN CAUDILL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 BLANDING BLVD
MIDDLEBURG FL
32068-3836
US

IV. Provider business mailing address

705 CYPRESS CROSSING TRL
SAINT AUGUSTINE FL
32095-6808
US

V. Phone/Fax

Practice location:
  • Phone: 574-551-5160
  • Fax:
Mailing address:
  • Phone: 574-551-5160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55108
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: