Provider Demographics
NPI:1124076856
Name:KAVANAUGH, BARRY L JR (OD PA)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:L
Last Name:KAVANAUGH
Suffix:JR
Gender:M
Credentials:OD PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376-0839
Mailing Address - Country:US
Mailing Address - Phone:910-673-3937
Mailing Address - Fax:910-673-3266
Practice Address - Street 1:1110 SEVEN LAKES DR
Practice Address - Street 2:
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376-9756
Practice Address - Country:US
Practice Address - Phone:910-673-3937
Practice Address - Fax:910-673-3266
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC1295152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC246620BMedicare PIN
NC1310650001Medicare NSC