Provider Demographics
NPI:1205921368
Name:CAVANAGH, JOHN MARK (OD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARK
Last Name:CAVANAGH
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 1:2655 INNSBRUCK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-9303
Mailing Address - Country:US
Mailing Address - Phone:651-636-2020
Mailing Address - Fax:651-633-5036
Practice Address - Street 1:2655 INNSBRUCK DR
Practice Address - Street 2:SUITE B
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-9303
Practice Address - Country:US
Practice Address - Phone:651-636-2020
Practice Address - Fax:651-633-5036
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT90870Medicare UPIN
MNC01706Medicare UPIN