Provider Demographics
NPI:1972535664
Name:CAICEDO, MARCO LEONARDO (MD)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:LEONARDO
Last Name:CAICEDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1597 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1915
Mailing Address - Country:US
Mailing Address - Phone:617-708-8300
Mailing Address - Fax:
Practice Address - Street 1:25 STANIFORD ST
Practice Address - Street 2:COMMONWEALTH OF MASS-ERICH LINDEMANN MHC
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2503
Practice Address - Country:US
Practice Address - Phone:617-626-6953
Practice Address - Fax:617-305-9958
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1560432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAH07204Medicare UPIN