Provider Demographics
NPI:1215921168
Name:KAVANAGH, JOSEPH EDWARD TERENCE (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:EDWARD TERENCE
Last Name:KAVANAGH
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 1:2660 SOUTH ST SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6230
Mailing Address - Country:US
Mailing Address - Phone:330-393-5544
Mailing Address - Fax:330-393-5546
Practice Address - Street 1:2660 SOUTH ST SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6230
Practice Address - Country:US
Practice Address - Phone:330-393-5544
Practice Address - Fax:330-393-5546
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-31352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0172085Medicaid
OH0172085Medicaid
OHD31890Medicare UPIN