Provider Demographics
NPI:1043273188
Name:CAVAGNOL, ROBERT M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:CAVAGNOL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1965 S FREMONT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2201
Mailing Address - Country:US
Mailing Address - Phone:417-820-3800
Mailing Address - Fax:417-820-3810
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-3800
Practice Address - Fax:417-820-3810
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086247208600000X
MO2007026645208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR168867001Medicaid
MO431560263OtherTRICARE WEST
P00709670OtherRAILROAD MEDICARE
MO1043273188Medicaid
P00709670OtherRAILROAD MEDICARE
MO431560263OtherTRICARE WEST