Healthcare Provider Details

I. General information

NPI: 1902999055
Provider Name (Legal Business Name): SUSAN CALDECOTT-JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 CLEARVISTA DR SUITE 5300
INDIANAPOLIS IN
46256-1621
US

IV. Provider business mailing address

6626 E 75TH ST 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-0104
  • Fax: 317-621-0111
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01043182A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberTEMPORARY
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number01043182A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: