Provider Demographics
NPI:1881986909
Name:CALDWELL, KEVIN JOSEPH
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:CALDWELL
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:PO BOX 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-8856
Mailing Address - Fax:217-545-2563
Practice Address - Street 1:33664 BAYVIEW MEDICAL DR UNIT 2
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1687
Practice Address - Country:US
Practice Address - Phone:302-644-4954
Practice Address - Fax:302-645-5481
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-08
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.0625502086S0129X
DEC1-00128262086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery