Provider Demographics
NPI:1891739991
Name:CANAVAN, MICHAEL T (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:CANAVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 PINEY FOREST RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2877
Mailing Address - Country:US
Mailing Address - Phone:434-799-9430
Mailing Address - Fax:434-792-8438
Practice Address - Street 1:789 PINEY FOREST RD
Practice Address - Street 2:SUITE B
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2877
Practice Address - Country:US
Practice Address - Phone:434-799-9430
Practice Address - Fax:434-792-8438
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103 000583213E00000X
NC219213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA017094OtherANTHEM
NC890803NOtherBCBS OF NORTH CAROLINA
VA009301631Medicaid
VA009301631Medicaid
VA480000056Medicare PIN