Provider Demographics
NPI:1528008695
Name:CALDWELL, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:CALDWELL
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:PO BOX 4328
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71134-0328
Mailing Address - Country:US
Mailing Address - Phone:318-222-1149
Mailing Address - Fax:318-425-2335
Practice Address - Street 1:1020 W FERTITTA BLVD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4649
Practice Address - Country:US
Practice Address - Phone:337-239-9041
Practice Address - Fax:337-239-5360
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.15763R207ZP0105X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1722669Medicaid
I48694Medicare UPIN
LA4K027CT24Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID