Provider Demographics
NPI:1720171283
Name:CAVANAUGH, DEBORAH SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:SUSAN
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 SAINT ANTHONY BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3154
Mailing Address - Country:US
Mailing Address - Phone:605-321-2549
Mailing Address - Fax:
Practice Address - Street 1:6341 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4946
Practice Address - Country:US
Practice Address - Phone:763-572-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD51992084P0800X
MN455232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7100518Medicaid
SD7100513Medicaid
SD7100518Medicaid
SD41411Medicare ID - Type Unspecified
SD7100513Medicaid