Provider Demographics
NPI:1356413173
Name:CAVENDER, DAVID E (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:CAVENDER
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 1:1700 E WEST RD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5415
Mailing Address - Country:US
Mailing Address - Phone:708-891-3330
Mailing Address - Fax:708-891-0904
Practice Address - Street 1:1700 E WEST RD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5415
Practice Address - Country:US
Practice Address - Phone:708-891-3330
Practice Address - Fax:708-891-0904
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL436350006OtherMEDICARE PTAN
IL046008327Medicaid
ILU79877Medicare UPIN
ILL77656Medicare ID - Type Unspecified