Provider Demographics
NPI:1710974019
Name:CAVINS, THERESA A (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:CAVINS
Suffix:
Gender:F
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:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-0366
Mailing Address - Country:US
Mailing Address - Phone:573-883-4477
Mailing Address - Fax:573-883-4477
Practice Address - Street 1:255 BODERMAN
Practice Address - Street 2:
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627-9099
Practice Address - Country:US
Practice Address - Phone:573-483-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-02
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110454208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO020048156OtherRAILROAD MEDICARE
MO012012273Medicare ID - Type Unspecified
MO135350016Medicare Oscar/Certification
MOH26473Medicare UPIN