Provider Demographics
NPI:1124183660
Name:CAVANAUGH, JASON EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:EDWARD
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:87 DICKINSON RD
Mailing Address - Street 2:
Mailing Address - City:S GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073
Mailing Address - Country:US
Mailing Address - Phone:860-376-8431
Mailing Address - Fax:860-376-8851
Practice Address - Street 1:180 RIVER RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:CT
Practice Address - Zip Code:06351
Practice Address - Country:US
Practice Address - Phone:860-376-8431
Practice Address - Fax:860-376-8851
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT2520152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist