Basic Information
| Provider Information | |||||||||
| NPI: | 1194796110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAEDO | ||||||||
| FirstName: | CARMELITA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2108 | ||||||||
| Address2: | |||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679052108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166856236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 315 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679012455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206241651 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | 04-17155 | KS | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 029854 | 01 | KS | BCBS | OTHER |