Individual
DR. PETER CACCAVALLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
13000 E 136TH ST, SUITE 1100, FISHERS, IN 46037-9478
(317) 678-3585
(317) 863-5084
Mailing address
13000 E 136TH ST, SUITE 1100, FISHERS, IN 46037-9478
(317) 678-3585
(317) 863-5084
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
1053181A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000287592
ANTHEM ID NUMBER
IN
05
—
200316800
—
IN
01
—
51-0456750
TAX ID
IN
01
—
P00013960
RAILROAD MEDICARE
IN
Enumeration date
01/16/2007
Last updated
07/14/2014
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