Provider Demographics
NPI:1376713685
Name:BARRY L KAVANAUGH JR OD PA
Entity Type:Organization
Organization Name:BARRY L KAVANAUGH JR OD PA
Other - Org Name:SEVEN LAKES EYE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:LAURENCE
Authorized Official - Last Name:KAVANAUGH
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:910-673-3937
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:1110 SEVEN LAKES DR
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376-0839
Mailing Address - Country:US
Mailing Address - Phone:910-673-3937
Mailing Address - Fax:910-673-3266
Practice Address - Street 1:1110 SEVEN LAKES DR
Practice Address - Street 2:
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376
Practice Address - Country:US
Practice Address - Phone:910-673-3937
Practice Address - Fax:910-673-3266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1295152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7909342Medicaid
NC7909342Medicaid