Provider Demographics
NPI:1376571638
Name:CAVANAUGH, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 PROFESSIONAL LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6972
Mailing Address - Country:US
Mailing Address - Phone:303-772-1600
Mailing Address - Fax:303-772-9317
Practice Address - Street 1:1551 PROFESSIONAL LN
Practice Address - Street 2:SUITE 200
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6972
Practice Address - Country:US
Practice Address - Phone:303-772-1600
Practice Address - Fax:303-772-9317
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO16429207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01164292Medicaid
CO16429OtherSTATE LICENSE NUMBER
CO01164292Medicaid
CO16429OtherSTATE LICENSE NUMBER