Provider Demographics
NPI:1306341227
Name:CAVANNAUGH, EDWIN CORNELLE IV (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:CORNELLE
Last Name:CAVANNAUGH
Suffix:IV
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 1:1900 E LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-1647
Mailing Address - Country:US
Mailing Address - Phone:714-888-5742
Mailing Address - Fax:
Practice Address - Street 1:1900 E LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-1647
Practice Address - Country:US
Practice Address - Phone:714-888-5742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA174005208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program