Provider Demographics
NPI:1104944263
Name:CAVAZOS, ANTHONY R (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:R
Last Name:CAVAZOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-2934
Mailing Address - Country:US
Mailing Address - Phone:908-679-8181
Mailing Address - Fax:908-679-8179
Practice Address - Street 1:29 SOUTH ST
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-2934
Practice Address - Country:US
Practice Address - Phone:908-679-8181
Practice Address - Fax:908-679-8179
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA071243002083P0500X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5221142040OtherBCBS OF NJ
NJ0203343Medicaid
04-29599OtherEVERCARE
043843QD1Medicare PIN
5221142040OtherBCBS OF NJ
E92779Medicare UPIN
043843XNMMedicare PIN