Provider Demographics
NPI:1750303434
Name:CAUDELLE, ROBERT KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KEITH
Last Name:CAUDELLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N JEFF DAVIS DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-461-2633
Mailing Address - Fax:770-461-5792
Practice Address - Street 1:320 N JEFF DAVIS DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-461-2633
Practice Address - Fax:770-461-5792
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1043152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410004213OtherRAILROAD MEDICARE
0866550001OtherDMERC
41ZCBSRMedicare ID - Type Unspecified
0866550001OtherDMERC