Provider Demographics
NPI:1528013372
Name:CAVALLO, UTHMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:UTHMAN
Middle Name:
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 1:53800 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1543
Mailing Address - Country:US
Mailing Address - Phone:574-273-3880
Mailing Address - Fax:571-271-0918
Practice Address - Street 1:53800 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635
Practice Address - Country:US
Practice Address - Phone:574-273-3880
Practice Address - Fax:571-271-0918
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054192A174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000742843OtherBCBS
IN200354000AMedicaid
IN000000760931OtherBCBS
IN735850RMedicare PIN
IN000000760931OtherBCBS