Provider Demographics
NPI:1104912153
Name:CAVANAUGH, DANIEL G (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:G
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:N1050 COUNTY ROAD O
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-8886
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N1050 COUNTY ROAD O
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-8886
Practice Address - Country:US
Practice Address - Phone:715-875-4402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27940208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30763200Medicaid
B51992Medicare UPIN
WI30763200Medicaid