Provider Demographics
NPI:1063407989
Name:CAVANNA, ANGELA C (DO)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:C
Last Name:CAVANNA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GLENN POND ROAD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RED HOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12571-1824
Mailing Address - Country:US
Mailing Address - Phone:845-758-6046
Mailing Address - Fax:845-758-6051
Practice Address - Street 1:17 GLENN POND ROAD
Practice Address - Street 2:SUITE 3
Practice Address - City:RED HOOK
Practice Address - State:NY
Practice Address - Zip Code:12571-1824
Practice Address - Country:US
Practice Address - Phone:845-758-6046
Practice Address - Fax:845-758-6051
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187748207R00000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01635890Medicaid
NYRB5787Medicare PIN
NY30507NW001Medicare PIN
NYF77490Medicare UPIN