Provider Demographics
NPI:1770570772
Name:CAUDLE, SCOTT O (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:O
Last Name:CAUDLE
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1503 W ELK AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2876
Mailing Address - Country:US
Mailing Address - Phone:423-543-8619
Mailing Address - Fax:423-543-5133
Practice Address - Street 1:1503 W ELK AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2876
Practice Address - Country:US
Practice Address - Phone:423-543-8619
Practice Address - Fax:423-543-5133
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2010-11-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNMA13233208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380824Medicaid
TN39248OtherBLUE CROSS BLUE SHIELD
A97486Medicare UPIN
TNA97486Medicare UPIN