Basic Information
Provider Information | |||||||||
NPI: | 1952392532 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CALDWELL | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | THOMAS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2000 OPELOUSAS STREET | ||||||||
Address2: |   | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 70601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374399983 | ||||||||
FaxNumber: | 3373101161 | ||||||||
Practice Location | |||||||||
Address1: | 2000 OPELOUSAS STREET | ||||||||
Address2: |   | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 70601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3374399983 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2005 | ||||||||
LastUpdateDate: | 12/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0010X | F3804 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 207Q00000X | 24446 | CO | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | F3804 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207RS0010X | 24446 | CO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 207Q00000X | 2014-0048 | NM | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207RS0010X | 2014-0048 | NM | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 207Q00000X | MD.207803 | LA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207RS0010X | MD.207803 | LA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 643610 | 05 | AZ |   | MEDICAID | 16704070 | 05 | CO |   | MEDICAID | S1607 | 05 | NM |   | MEDICAID |