Provider Demographics
NPI:1497755136
Name:CAUDELL, RICHARD L (DPM)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
Last Name:CAUDELL
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 1:3660 BOULEVARD
Mailing Address - Street 2:STE B
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1345
Mailing Address - Country:US
Mailing Address - Phone:804-520-4144
Mailing Address - Fax:804-520-4144
Practice Address - Street 1:3660 BOULEVARD
Practice Address - Street 2:STE B
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1345
Practice Address - Country:US
Practice Address - Phone:804-520-4144
Practice Address - Fax:804-520-4144
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000442213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009301569Medicaid
U28076Medicare UPIN
VA480953071Medicare ID - Type Unspecified