Provider Demographics
NPI:1730140583
Name:CAVACINI, TIMOTHY J (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:CAVACINI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 SOUTHPARK CIR E
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5135
Mailing Address - Country:US
Mailing Address - Phone:904-824-6108
Mailing Address - Fax:904-823-9613
Practice Address - Street 1:216 SOUTHPARK CIR E
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5135
Practice Address - Country:US
Practice Address - Phone:904-824-6108
Practice Address - Fax:904-823-9613
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0007112207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379819400Medicaid
FLF40798Medicare UPIN
FL57296Medicare ID - Type Unspecified