Provider Demographics
NPI:1336428812
Name:KAVENAUGH, ANGELA LEIGH (DO)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:LEIGH
Last Name:KAVENAUGH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4201 ST. ANTOINE UHC 5D
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:3901 BEAUBIEN ER DEPT
Practice Address - Street 2:CHILDREN'S HOSPITAL OF MI
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-5260
Practice Address - Fax:313-993-7166
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101021517208000000X
WVED0251A207R00000X
FLUO3116208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVED0251AOtherWEST VIRGINIA EDUCATION LICENSE
FLUO3116OtherTRAINING LICENSE