MEDICARE: MEMORIE VANESSA CALDWELL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	ME147306	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194245159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEMORIE VANESSA CALDWELL MD

Provider Business Mailing Address
First Line	:	4205 BELFORT RD STE 4015
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-3623
Country	:	US
Telephone Number	:	904-450-6017
Fax Number	:	904-450-6041

Provider Business Practice Location Address
First Line	:	6488 103RD ST STE B
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-7161
Country	:	US
Telephone Number	:	904-450-6810
Fax Number	:	904-450-6729

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	12/03/2020

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