Healthcare Provider Details

I. General information

NPI: 1821060781
Provider Name (Legal Business Name): MISTY DAWN CAUDELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 JESSE JEWELL PKWY SE STE D
GAINESVILLE GA
30501-3874
US

IV. Provider business mailing address

PO BOX 1456
GAINESVILLE GA
30503-1456
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-7546
  • Fax: 770-535-7591
Mailing address:
  • Phone: 770-535-7546
  • Fax: 770-535-7591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD425726
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number15031
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number058402
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: