Healthcare Provider Details

I. General information

NPI: 1013188291
Provider Name (Legal Business Name): GAGE MANNING CAUDELL D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 W JEFFERSON BLVD
FORT WAYNE IN
46804-4133
US

IV. Provider business mailing address

PO BOX 2526
FORT WAYNE IN
46801-2526
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-8686
  • Fax: 260-436-8585
Mailing address:
  • Phone: 260-436-8686
  • Fax: 260-436-8585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001098A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36003452
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: