Provider Demographics
NPI:1093128589
Name:CALDWELL, MARK PORTER (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PORTER
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1788 PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-6254
Mailing Address - Country:US
Mailing Address - Phone:480-272-5674
Mailing Address - Fax:
Practice Address - Street 1:1788 PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937
Practice Address - Country:US
Practice Address - Phone:480-272-5674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10933225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist