Provider Demographics
NPI:1235140278
Name:CAVINESS, RANDALL ELTON (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ELTON
Last Name:CAVINESS
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 1:944 BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2818
Mailing Address - Country:US
Mailing Address - Phone:530-898-1742
Mailing Address - Fax:
Practice Address - Street 1:1279 E 1ST AVE STE A
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1542
Practice Address - Country:US
Practice Address - Phone:530-891-9531
Practice Address - Fax:530-891-9533
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 73893208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G738930Medicare ID - Type UnspecifiedPROVIDER NUMBER
F340987Medicare UPIN