Provider Demographics
NPI:1548232879
Name:CAVETT, CLINTON (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:CAVETT
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 1:6626 E 75TH ST
Mailing Address - Street 2:500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8040 CLEARVISTA PKWY
Practice Address - Street 2:SUITE 460
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5630
Practice Address - Country:US
Practice Address - Phone:317-621-2660
Practice Address - Fax:317-621-1535
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-0480412086S0120X
IN01068359A2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000765121OtherANTHEM
IN20093210Medicaid
VA6754139Medicaid
IN000000765121OtherANTHEM
VAD82453Medicare UPIN
IN20093210Medicaid
VA6754139Medicaid