Healthcare Provider Details

I. General information

NPI: 1033180054
Provider Name (Legal Business Name): CARMELITA CAEDO MD RADIOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 15TH ST
LIBERAL KS
67901-2455
US

IV. Provider business mailing address

PO BOX 2108
LIBERAL KS
67905-2108
US

V. Phone/Fax

Practice location:
  • Phone: 620-624-1651
  • Fax:
Mailing address:
  • Phone: 316-685-6236
  • Fax: 316-652-0340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CARMELITA CAEDO
Title or Position: PRESIDENT
Credential: MD
Phone: 620-624-1651