Provider Demographics
NPI:1619464252
Name:CALDERON, ENRIQUE C
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:C
Last Name:CALDERON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 58TH ST S APT 113
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-6001
Mailing Address - Country:US
Mailing Address - Phone:813-879-1200
Mailing Address - Fax:
Practice Address - Street 1:5838 54TH AVE N
Practice Address - Street 2:
Practice Address - City:KENNETH CITY
Practice Address - State:FL
Practice Address - Zip Code:33709-1902
Practice Address - Country:US
Practice Address - Phone:813-879-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies