Provider Demographics
NPI:1265650295
Name:CAUDILL, JEREMY ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:ALAN
Last Name:CAUDILL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2460 OLD MOULTRIE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4198
Mailing Address - Country:US
Mailing Address - Phone:904-797-6627
Mailing Address - Fax:904-797-6028
Practice Address - Street 1:2460 OLD MOULTRIE RD STE 3
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4198
Practice Address - Country:US
Practice Address - Phone:904-797-6627
Practice Address - Fax:386-328-4125
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10861208600000X
MI5101016585208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003413200Medicaid
FL002389800Medicaid