Provider Demographics
NPI:1740391390
Name:KAVANAGH, JOEL B (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:B
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 1:1650 CARROL DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-4301
Mailing Address - Country:US
Mailing Address - Phone:228-206-4312
Mailing Address - Fax:
Practice Address - Street 1:1650 CARROL DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4301
Practice Address - Country:US
Practice Address - Phone:228-206-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17254207R00000X, 208M00000X, 174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03551501Medicaid
MSMEDICARE RROther110222271
MS7927259OtherAETNA
MS0124651Medicaid
MS0124651Medicaid
MSMEDICARE RROther110222271
MS7927259OtherAETNA