Provider Demographics
NPI:1851063002
Name:CAVANAUGH, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:CAVANAUGH
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:PO BOX 1407
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46308-1407
Mailing Address - Country:US
Mailing Address - Phone:219-670-5376
Mailing Address - Fax:
Practice Address - Street 1:521 W MCCARTY ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46225-1239
Practice Address - Country:US
Practice Address - Phone:317-327-4794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01045676A207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic PathologyGroup - Single Specialty