Provider Demographics
NPI:1952690224
Name:CADDELL, KIRK ALLAN (MD)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:ALLAN
Last Name:CADDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-2266
Mailing Address - Fax:
Practice Address - Street 1:3024 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1247
Practice Address - Country:US
Practice Address - Phone:919-350-2266
Practice Address - Fax:919-350-7687
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-02505208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1952690224Medicaid