Provider Demographics
NPI:1730257411
Name:CALDWELL, KATHERINE R (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:R
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:STE 700
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2443
Practice Address - Country:US
Practice Address - Phone:207-774-5816
Practice Address - Fax:207-523-8597
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC05076207R00000X
ME017709207R00000X
MN55033207R00000X
MEMD17709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432856099Medicaid
ME432856099Medicaid
ME000469001Medicare PIN
MN110015462Medicare PIN