Provider Demographics
NPI:1093918542
Name:KAVANAGH, DAVID WILLIAM (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WILLIAM
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 54TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1703
Mailing Address - Country:US
Mailing Address - Phone:727-545-9902
Mailing Address - Fax:727-457-0264
Practice Address - Street 1:6321 54TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-1703
Practice Address - Country:US
Practice Address - Phone:727-545-9902
Practice Address - Fax:727-457-0264
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1144315391OtherFACILITY NPI NUMBER
FLGG9OtherBCBS FACILITY PROVIDER NO
FL686704Medicare Oscar/Certification