Provider Demographics
NPI:1558308239
Name:CALDWELL, FRED M (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
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 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:225 PHYSICIANS PARK STE 400
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3923
Practice Address - Country:US
Practice Address - Phone:573-727-5500
Practice Address - Fax:573-727-5599
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36656207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202642906Medicaid
MO001013328Medicare PIN
MO110215340Medicare PIN
MO202642906Medicaid