Provider Demographics
NPI:1851400691
Name:MITRE CALDERON, NAIM GUSTAVO DEL CARMEN (MD)
Entity Type:Individual
Prefix:
First Name:NAIM
Middle Name:GUSTAVO DEL CARMEN
Last Name:MITRE CALDERON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NAIM
Other - Middle Name:G
Other - Last Name:MITRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2401 GILLHAM RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-234-3000
Mailing Address - Fax:
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:816-234-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080359812080P0205X
KS04-334682080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN221955000Medicaid
I 58089Medicare UPIN
MN221955000Medicaid