Provider Demographics
NPI:1871680199
Name:SMITH-CAILLOUET, LYNETTE (MD)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:SMITH-CAILLOUET
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 1:6920 POINTE INVERNESS WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 W 12TH ST STE 106
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1654
Practice Address - Country:US
Practice Address - Phone:765-472-8041
Practice Address - Fax:260-479-2926
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097814207R00000X
IN01070112A207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01210504OtherRR MEDICARE PTAN
INP01270958OtherRR MEDICARE
INP01227271OtherRR MEDICARE PTAN
IN200218630Medicaid
ILG78650Medicare UPIN
IL6447860014Medicare NSC
ININ1663005Medicare PIN
IN266180209Medicare PIN
ILIL3270247Medicare PIN
IL0533210001Medicare NSC
INM400076186Medicare PIN
G78650Medicare UPIN
IN200218630Medicaid