Provider Demographics
NPI:1295814176
Name:CAVANAUGH, ROBERT ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:CAVANAUGH
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1800 LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9108
Practice Address - Country:US
Practice Address - Phone:920-983-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25135207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30522900Medicaid
WI30522900Medicaid
WI073550103Medicare Oscar/Certification
WI430800040Medicare Oscar/Certification
WI075100135Medicare Oscar/Certification
WI073100057Medicare Oscar/Certification
WI330000038Medicare Oscar/Certification
WI072250047Medicare Oscar/Certification
WI330350046Medicare Oscar/Certification
B51993Medicare UPIN
WI030280041Medicare Oscar/Certification
WI030280041Medicare Oscar/Certification