Provider Demographics
NPI:1043393820
Name:CAUDELL, PATRICIA A (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:CAUDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844590
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1462 LANEY WALKER BLVD
Practice Address - Street 2:CA-2105
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0003
Practice Address - Country:US
Practice Address - Phone:706-721-9341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041412207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000787663CMedicaid
GAG69790Medicare UPIN
GA22BDDTKMedicare PIN