Healthcare Provider Details

I. General information

NPI: 1346224086
Provider Name (Legal Business Name): ALLAN D CAUDILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BLUE STAR HWY
SOUTH HAVEN MI
49090-7758
US

IV. Provider business mailing address

955 S BAILEY AVE
SOUTH HAVEN MI
49090-6743
US

V. Phone/Fax

Practice location:
  • Phone: 269-639-2893
  • Fax:
Mailing address:
  • Phone: 269-639-2874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101235364
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301050127
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: