Provider Demographics
NPI:1346224086
Name:CAUDILL, ALLAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:D
Last Name:CAUDILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-6743
Mailing Address - Country:US
Mailing Address - Phone:269-639-2874
Mailing Address - Fax:
Practice Address - Street 1:940 BLUE STAR HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7758
Practice Address - Country:US
Practice Address - Phone:269-639-2893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235364208600000X
MI4301050127208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010011795Medicaid
VA010011795Medicaid
A76816Medicare UPIN