Provider Demographics
NPI:1518956655
Name:KAVANAGH, TODD C (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:C
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11725 STINSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-9542
Mailing Address - Country:US
Mailing Address - Phone:651-257-8421
Mailing Address - Fax:
Practice Address - Street 1:5200 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8013
Practice Address - Country:US
Practice Address - Phone:651-982-7723
Practice Address - Fax:651-982-7677
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2867152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN124140100Medicaid
MN124140100Medicaid
MN4602400003Medicare NSC
MNH67405Medicare UPIN
MN4602400004Medicare NSC
MN4602400001Medicare NSC