Provider Demographics
NPI:1851471577
Name:MCAVOY, MICHAEL S (OD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:S
Last Name:MCAVOY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 BUNKER HILL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019
Mailing Address - Country:US
Mailing Address - Phone:860-693-8088
Mailing Address - Fax:
Practice Address - Street 1:235 QUEEN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1915
Practice Address - Country:US
Practice Address - Phone:860-628-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004162301Medicaid
CT410000676Medicare ID - Type Unspecified
CTT22343Medicare UPIN
CT004162301Medicaid