Provider Demographics
NPI:1528374626
Name:SMALL, CALVIN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:JOSEPH
Last Name:SMALL
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 1:1832 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2814
Mailing Address - Country:US
Mailing Address - Phone:215-787-0244
Mailing Address - Fax:
Practice Address - Street 1:1832 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-2814
Practice Address - Country:US
Practice Address - Phone:215-787-0244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426237207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF11978Medicare UPIN