Provider Demographics
NPI:1366448680
Name:CALDWELL, BRYAN DEWITT (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DEWITT
Last Name:CALDWELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 EUCLID AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-3759
Mailing Address - Country:US
Mailing Address - Phone:216-231-5612
Mailing Address - Fax:216-721-5534
Practice Address - Street 1:4415 EUCLID AVE STE 110
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-3759
Practice Address - Country:US
Practice Address - Phone:216-231-5612
Practice Address - Fax:216-721-5534
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36 002681213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0982227Medicaid
OH1563848OtherMEDICAID GROUP
OHCH5179OtherRR MEDICARE GROUP
OH480031311OtherRR MEDICARE
OH0766954Medicare PIN
OH4310000001Medicare NSC
OHCH5179OtherRR MEDICARE GROUP
OH0982227Medicaid