Provider Demographics
NPI:1306831458
Name:CABALLERO, RENATO M (MD)
Entity Type:Individual
Prefix:DR
First Name:RENATO
Middle Name:M
Last Name:CABALLERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502
Mailing Address - Country:US
Mailing Address - Phone:580-357-9984
Mailing Address - Fax:580-357-3277
Practice Address - Street 1:3201 W GORE BLVD
Practice Address - Street 2:STE 301
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-248-8225
Practice Address - Fax:580-248-8919
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK14902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK404757OtherAETNA
080194100OtherRAILROAD MEDICARE
OK100138580BOtherSOONERCARE CHOICE
OK125324500OtherDOL
OK100138580CMedicaid
OK100138580CMedicaid
OK100138580BOtherSOONERCARE CHOICE