Provider Demographics
NPI:1801467485
Name:BEATTIE, CALEB JORDAN (IDC)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:JORDAN
Last Name:BEATTIE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3399 STRAUSS AVE STE 219
Mailing Address - Street 2:
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-5164
Mailing Address - Country:US
Mailing Address - Phone:904-718-1179
Mailing Address - Fax:
Practice Address - Street 1:3399 STRAUSS AVE STE 219
Practice Address - Street 2:
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-5164
Practice Address - Country:US
Practice Address - Phone:904-718-1179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman