Provider Demographics
NPI:1780676254
Name:CALDWELL, DAN (OD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:CALDWELL
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 1:125 NW MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7225
Mailing Address - Country:US
Mailing Address - Phone:503-665-5415
Mailing Address - Fax:503-492-2313
Practice Address - Street 1:125 NW MILLER AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7225
Practice Address - Country:US
Practice Address - Phone:503-665-5415
Practice Address - Fax:503-492-2313
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1627T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR290155Medicaid
ORT67476Medicare UPIN
OR104413Medicare ID - Type Unspecified