Provider Demographics
NPI:1043490113
Name:CAICEDO, JENNIFER LAIACONA (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAIACONA
Last Name:CAICEDO
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 1:8045 PROVIDENCE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8915
Mailing Address - Country:US
Mailing Address - Phone:704-341-9600
Mailing Address - Fax:855-380-3762
Practice Address - Street 1:8045 PROVIDENCE RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-341-9600
Practice Address - Fax:855-380-3762
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00855208000000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA53535215Medicaid
NC10434901113Medicaid
NCNCD163AMedicare PIN
NC2325437Medicare PIN
NC2075532Medicare Oscar/Certification
NCNCD163B833Medicare PIN
SC324090Medicare PIN