Provider Demographics
NPI:1205987252
Name:CACCAVALLO, PETER
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:CACCAVALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 E 136TH ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9478
Mailing Address - Country:US
Mailing Address - Phone:317-678-3585
Mailing Address - Fax:317-863-5084
Practice Address - Street 1:13000 E 136TH ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9478
Practice Address - Country:US
Practice Address - Phone:317-678-3585
Practice Address - Fax:317-863-5084
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1053181A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN51-0456750OtherTAX ID
IN000000287592OtherANTHEM ID NUMBER
IN200316800Medicaid
INP00013960OtherRAILROAD MEDICARE
INH31559Medicare UPIN
IN202680AMedicare ID - Type UnspecifiedMEDICARE ID NUMBER