Provider Demographics
NPI:1760403091
Name:CACCAM, EVALEEN FAYE (MD)
Entity Type:Individual
Prefix:
First Name:EVALEEN
Middle Name:FAYE
Last Name:CACCAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 MERRIMAC AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1850
Mailing Address - Country:US
Mailing Address - Phone:904-346-0050
Mailing Address - Fax:904-346-0080
Practice Address - Street 1:4425 MERRIMAC AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1850
Practice Address - Country:US
Practice Address - Phone:904-346-0050
Practice Address - Fax:904-346-0080
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89729207VG0400X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269890100Medicaid
FLI15457Medicare UPIN
FL48248ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER