Provider Demographics
NPI:1679683882
Name:KAVANAGH, GERALD JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:JAMES
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 1:443 19TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402-2431
Mailing Address - Country:US
Mailing Address - Phone:310-394-4405
Mailing Address - Fax:
Practice Address - Street 1:637 LUCAS AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1912
Practice Address - Country:US
Practice Address - Phone:213-977-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG18772174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG18772Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAA40418Medicare UPIN