Provider Demographics
NPI:1972528750
Name:CALDWELL, REYNAL LEON SR (DO)
Entity Type:Individual
Prefix:
First Name:REYNAL
Middle Name:LEON
Last Name:CALDWELL
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 NETHERTON DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-4697
Mailing Address - Country:US
Mailing Address - Phone:314-521-7768
Mailing Address - Fax:314-838-3683
Practice Address - Street 1:2880 NETHERTON DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-4697
Practice Address - Country:US
Practice Address - Phone:314-521-7768
Practice Address - Fax:314-838-3683
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5E11207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242386712Medicaid
MO242386712Medicaid
A10270Medicare UPIN