Healthcare Provider Details

I. General information

NPI: 1093152589
Provider Name (Legal Business Name): UTHMAN CAVALLO, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53800 GENERATIONS DR
SOUTH BEND IN
46635-1543
US

IV. Provider business mailing address

53800 GENERATIONS DR
SOUTH BEND IN
46635-1543
US

V. Phone/Fax

Practice location:
  • Phone: 574-273-3880
  • Fax: 574-271-0918
Mailing address:
  • Phone: 574-273-3880
  • Fax: 574-271-0918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: UTHMAN CAVALLO
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 574-273-3880