Provider Demographics
NPI:1154642551
Name:CADDELL, HEATHER OTTMERS (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:OTTMERS
Last Name:CADDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:OTTMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1355 CENTRAL PKWY S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-5055
Mailing Address - Country:US
Mailing Address - Phone:210-590-6195
Mailing Address - Fax:210-650-5993
Practice Address - Street 1:124 E BANDERA RD
Practice Address - Street 2:SUITE 204
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2849
Practice Address - Country:US
Practice Address - Phone:210-653-5501
Practice Address - Fax:210-650-5975
Is Sole Proprietor?:No
Enumeration Date:2010-06-20
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP9817207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340602701Medicaid
TX363443YPW5Medicare PIN