Provider Demographics
NPI:1558514380
Name:KAVANAGH, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:KAVANAGH
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 1:61 BEAVERBROOK RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1748
Mailing Address - Country:US
Mailing Address - Phone:973-686-9292
Mailing Address - Fax:973-686-9294
Practice Address - Street 1:61 BEAVERBROOK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1748
Practice Address - Country:US
Practice Address - Phone:973-686-9292
Practice Address - Fax:973-686-9294
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245447207XX0005X
NJ25MA08991900207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1558514380OtherBCBS
VA1558514380Medicaid
VA1558514380Medicaid