Provider Demographics
NPI:1619918208
Name:CAVANAUGH, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1 EXPRESSWAY PLAZA, SUITE 115
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577
Mailing Address - Country:US
Mailing Address - Phone:516-759-1131
Mailing Address - Fax:516-676-5727
Practice Address - Street 1:1 EXPRESSWAY PLAZA, SUITE 115
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577
Practice Address - Country:US
Practice Address - Phone:516-759-1131
Practice Address - Fax:516-676-5727
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY201939208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01841478Medicaid