Provider Demographics
NPI:1053304766
Name:KAVANAUGH, TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:KAVANAUGH
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 1:10200 N 92ND ST STE 225
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4536
Mailing Address - Country:US
Mailing Address - Phone:480-697-4824
Mailing Address - Fax:480-697-4825
Practice Address - Street 1:10200 N 92ND ST STE 225
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4536
Practice Address - Country:US
Practice Address - Phone:480-697-4824
Practice Address - Fax:480-697-4825
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4942207X00000X
AZ58251207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ997601Medicaid
AZZ228811OtherMEDICARE
AK160178Medicare ID - Type UnspecifiedNORIDIAN MEDICARE