1154642551 NPI number — DR. HEATHER OTTMERS CADDELL M.D.

Table of content: DR. HEATHER OTTMERS CADDELL M.D. (NPI 1154642551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154642551 NPI number — DR. HEATHER OTTMERS CADDELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CADDELL
Provider First Name:
HEATHER
Provider Middle Name:
OTTMERS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OTTMERS
Provider Other First Name:
HEATHER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154642551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1355 CENTRAL PKWY S
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232-5055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-590-6195
Provider Business Mailing Address Fax Number:
210-650-5993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 E BANDERA RD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
BOERNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78006-2849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-653-5501
Provider Business Practice Location Address Fax Number:
210-650-5975
Provider Enumeration Date:
06/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: P9817 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 340602701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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