Provider Demographics
NPI:1295231405
Name:KAVANAUGH, MICHELLE MARIA (OPHTHALMIC DISPENSER)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIA
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760
Mailing Address - Country:US
Mailing Address - Phone:607-321-8333
Mailing Address - Fax:
Practice Address - Street 1:3505 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760
Practice Address - Country:US
Practice Address - Phone:607-321-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009727156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician