Provider Demographics
NPI:1174733521
Name:CAVALLO, CHARLES ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:CAVALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:800-577-5368
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:3132 OLD JACKSONVILLE RD STE 110
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7401
Practice Address - Country:US
Practice Address - Phone:217-588-2600
Practice Address - Fax:217-862-0904
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036041159208600000X, 207R00000X
NY258002207Q00000X, 208600000X
IL036-041159207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC38230Medicare UPIN
NYJ400025295Medicare PIN
IL238240Medicare ID - Type Unspecified
NYJ400037370Medicare PIN