Provider Demographics
NPI:1619917549
Name:CAVALLO, MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:CAVALLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 WEST JOHNSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:EAST NORRITON
Mailing Address - State:PA
Mailing Address - Zip Code:19401
Mailing Address - Country:US
Mailing Address - Phone:484-808-8888
Mailing Address - Fax:484-808-8890
Practice Address - Street 1:304 WEST JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:EAST NORRITON
Practice Address - State:PA
Practice Address - Zip Code:19401
Practice Address - Country:US
Practice Address - Phone:484-808-8888
Practice Address - Fax:484-808-8890
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC3721L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA071294835Medicaid
PA0083207000OtherPA BLUE SHIELD
PACA139919Medicare ID - Type Unspecified
PA071294835Medicaid