Provider Demographics
NPI:1720045628
Name:CAUDILL, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:CAUDILL
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 1:1218 S BROADWAY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2759
Mailing Address - Country:US
Mailing Address - Phone:859-219-0542
Mailing Address - Fax:859-219-9433
Practice Address - Street 1:1218 S BROADWAY
Practice Address - Street 2:SUITE 310
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2759
Practice Address - Country:US
Practice Address - Phone:859-219-0542
Practice Address - Fax:859-219-9433
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY265832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64265838Medicaid
0572107Medicare PIN
0765703Medicare ID - Type Unspecified
0581309Medicare ID - Type Unspecified
0723603Medicare ID - Type Unspecified
0581209Medicare ID - Type Unspecified
0571907Medicare ID - Type Unspecified
0674606Medicare ID - Type Unspecified
0991703Medicare ID - Type Unspecified
0950503Medicare ID - Type Unspecified
KY64265838Medicaid
A17428Medicare UPIN
0571807Medicare ID - Type Unspecified
0946403Medicare ID - Type Unspecified