Provider Demographics
NPI:1508849399
Name:CAVALLO, CHARLES ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALBERT
Last Name:CAVALLO
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 1:2865 CHANCELLOR DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3912
Mailing Address - Country:US
Mailing Address - Phone:859-341-5400
Mailing Address - Fax:859-578-3172
Practice Address - Street 1:2865 CHANCELLOR DR
Practice Address - Street 2:SUITE 225
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3912
Practice Address - Country:US
Practice Address - Phone:859-341-5400
Practice Address - Fax:859-578-3172
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36719208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics