Provider Demographics
NPI:1942379664
Name:CAVANAUGH, THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:CAVANAUGH
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 1:3133 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2463
Mailing Address - Country:US
Mailing Address - Phone:530-888-0670
Mailing Address - Fax:530-888-8652
Practice Address - Street 1:3133 PROFESSIONAL DR
Practice Address - Street 2:SUITE 14
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2463
Practice Address - Country:US
Practice Address - Phone:530-888-0670
Practice Address - Fax:530-888-8652
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 5370 TPA152W00000X, 152WP0200X, 152WS0006X, 152WX0102X, 156FC0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT09965Medicare UPIN