Provider Demographics
NPI:1821198615
Name:CAYCEDO, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:CAYCEDO
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 1:341 LITTLE BEAR DR
Mailing Address - Street 2:CATAULA
Mailing Address - City:CATAULA
Mailing Address - State:GA
Mailing Address - Zip Code:31804-4466
Mailing Address - Country:US
Mailing Address - Phone:254-466-6640
Mailing Address - Fax:
Practice Address - Street 1:9200 MARNE ROAD
Practice Address - Street 2:MARTIN ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-544-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine