Provider Demographics
NPI:1164495842
Name:CALDWELL, JACQUETTE L (MD)
Entity Type:Individual
Prefix:
First Name:JACQUETTE
Middle Name:L
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUETTE
Other - Middle Name:L
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6439 GARNERS FERRY RD
Mailing Address - Street 2:DEPT OF RADIOLOGY
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1638
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:803-753-9570
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:803-753-9570
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-11
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0231052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCH33467Medicare UPIN
SCH334674823Medicare ID - Type Unspecified