Provider Demographics
NPI:1073621033
Name:CALDWELL, RANDALL L (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RR 127
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-8906
Practice Address - Fax:317-274-4022
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010238362080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100061190Medicaid
MI1073621033Medicaid
KY64882236Medicaid
350593390-042OtherTRICARE-DEAC-350593390
000000354895OtherANTHEM-DEAC-350593390
OH0472902Medicaid
IN100061190Medicaid
000000354895OtherANTHEM-DEAC-350593390
145590IMedicare ID - Type UnspecifiedUPA-237328642