Provider Demographics
NPI:1104917624
Name:KAVANAGH, CATHAL (DO)
Entity type:Individual
Prefix:
First Name:CATHAL
Middle Name:
Last Name:KAVANAGH
Suffix:
Gender:M
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:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-0468
Mailing Address - Country:US
Mailing Address - Phone:207-858-8353
Mailing Address - Fax:207-474-9261
Practice Address - Street 1:46 FAIRVIEW AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1481
Practice Address - Country:US
Practice Address - Phone:207-474-0905
Practice Address - Fax:207-474-6930
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO1818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1104917624Medicaid
I09461Medicare UPIN
I09461Medicare UPIN